Mar 23, 2016 | Article, Volume 6 - Issue 1
Nicole A. Stargell, Victoria E. Kress, Matthew J. Paylo, Alison Zins
Excoriation disorder, sometimes colloquially referred to as skin picking disorder, is a newly added disorder in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). Despite being a newly-classified DSM disorder, excoriation disorder is relatively common and affects between 1.4 and 5.4% of the general population (Grant et al., 2012). The purpose of this article is to provide professional counselors with a general understanding of how to assess, diagnose and treat excoriation disorder.
The prevalence of excoriation disorder may be underestimated, as it is sometimes overlooked, particularly because of comorbidity with other mental disorders (e.g., depression, anxiety, obsessive-compulsive disorder; Hayes, Storch, & Berlanga, 2009). Previously underestimated numbers of its prevalence also may be due to the covertness often associated with this disorder (Grant & Odlaug, 2009). Many people with excoriation disorder go to great lengths to hide their behavior from others (e.g., significant others, family members, health professionals) due to fear or embarassment.
Historically, excoriation disorder has been associated with obsessive-compulsive disorder (OCD), and it is now listed as a unique diagnosis in the obsessive-compulsive and related disorders section in the DSM-5 (Ravindran, da Silva, Ravindran, Richter, & Rector, 2009). According to the APA (2013), excoriation disorder involves the recurrent, excessive and often impulsive scratching, rubbing and picking of skin which leads to tissue damage and lesions. Those who have excoriation disorder frequently initiate attempts to eradicate these destructive behaviors, yet have difficulty doing so. In order for the diagnosis of excoriation disorder to be applied, individuals must experience clinically-significant distress or impairment in social, occupational or other important areas of functioning due to the routine nature of the skin picking behaviors (APA, 2013). Because of its physical manifestation, this phenomenon has frequently been discussed in medical research, but it is now receiving attention in mental health circles.
Etiology of Excoriation Disorder
Little is known about the etiology of excoriation disorder. Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar (Flessner, Berman, Garcia, Freeman, & Leonard, 2009). Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors (Grant et al., 2012).
Biological factors related to excoriation disorder include genetic predispositions and neurological sensitivity to emotional stimuli, which result in emotional impulsivity and a need to self-soothe (Snorrason, Smári, & Ólafsson, 2011). In one study of 40 individuals who had excoriation disorder, 43% had a first-degree relative with the disorder (Neziroglu, Rabinowitz, Breytman, & Jacofsky, 2008). Specific genes (e.g., Hoxb8 and SAPAP3) have been identified as potential predictors of this disorder (Grant et al., 2012). In animal studies, mice with these genes engaged in excessive grooming to the point of skin lesions, behaviors similar to those of people who have excoriation disorder (Grant et al., 2012). Conversely, in another study, humans with the SAPAP3 gene only met criteria for excoriation disorder 20% of the time (Dufour et al., 2010). It is important to note that genetics appear to play a role in the development of excoriation disorder, but other factors contribute to the disorder’s etiology and maintenance as well (Grant et al., 2012; Lang et al., 2010).
In terms of psychological factors, skin picking behaviors help regulate uncomfortable emotions and can become a behaviorally-reinforced coping mechanism used to manage negative feelings (Lang et al., 2010). Some researchers suggest that excoriation disorder is rooted in higher levels of emotional impulsivity and that this characteristic supports and encourages the development of the disorder (Grant et al., 2012). Those with excoriation disorder experience obsessive thoughts about skin picking and engage in more impulsive, sensation-seeking behaviors (e.g., picking, rubbing) than those without the disorder (Snorrason et al., 2011). Those with excoriation disorder often have a greater difficulty with response inhibition and an increased difficulty suppressing an already initiated response as compared to control participants (Grant, Odlaug, & Chamberlain, 2011; Odlaug & Grant, 2010). For example, it might be more difficult for those with excoriation disorder to retract their hand if they already started reaching for an object to use to excoriate. This elevated level of impulsivity may be rooted in brain abnormalities; however, further research is necessary to clearly establish this connection (Grant et al., 2012).
Another common theory regarding the onset and maintenance of excoriation disorder is that skin picking behaviors can help regulate emotions and can become a behaviorally-reinforced coping mechanism used to manage elevated levels of anxiety, stress and arousal. Individuals who skin pick often display elevated stress responses to normal stimuli (Lang et al., 2010), and skin picking appears to temporarily sooth such stress. Additionally, obsessive thoughts about skin imperfections and anxiety over not picking can be temporarily relieved by completing the behaviors (Capriotti, Ely, Snorrason, & Woods, 2015). As such, there is a behavioral component—in addition to the genetic and biological components of the disorder—that must be considered when understanding the etiology, assessment, diagnosis and treatment of excoriation disorder.
Assessment and Diagnosis of Excoriation Disorder
The proposed etiologies (e.g., genetic predispositions, biological markers) and functions (e.g., soothing emotional reactivity, reducing obsessive thoughts) of excoriation disorder inform the diagnostic and assessment process. It is important that counselors have a thorough understanding of the DSM-5 criteria for excoriation disorder and understand that many clients with this disorder might hide physical markers and omit skin picking information unless asked directly (Grant & Odlaug, 2009). As such, counselors might use formal assessments, in addition to clinical judgment, in order to make an accurate diagnosis and best understand the client’s behaviors.
Assessment
A number of assessment tools can be used to assist in assessing, diagnosing and treating those who have excoriation disorder. Each measure can be utilized by counselors in developing a holistic conceptualization of the client and for engaging in differential diagnosis. Upon accurate diagnosis of excoriation disorder, assessment measures also can aid counselors in selecting appropriate treatment goals, interventions and modalities for each client, and they can be used to assess client behavior change.
Keuthen et al. (2001b) constructed three skin picking scales that can be used to assess excoriation disorder and aid in the assessment and treatment process. The first measure, the Skin Picking Scale (SPS), can be used to measure the client’s self-reported severity of skin picking behaviors. This measure consists of six items that relate to the frequency of picking urges, intensity of picking urges, time spent engaging in skin picking behaviors, interference of the behaviors in functioning, avoidance behaviors and the overall distress associated with the excoriation-related behaviors. Each item is assessed on a 5-point scale of 0 (none) to 4 (extreme), resulting in a range of total scores between 0 and 24. The SPS demonstrated high internal consistency with adequate convergent validity (Keuthen et al., 2001a). Pragmatically, this measure can be used to distinguish self-injurious skin picking from non-self-injurious skin picking. As treatment gains are made, corresponding scores should decrease.
The second measure is the Skin Picking Impact Scale (SPIS). The SPIS is a self-report questionnaire designed to assess the impacts or consequences of repetitive skin picking (e.g., negative self-evaluation, social interference; Keuthen et al., 2001a). Each of the scale’s 10 items are rated on a 6-point scale from 0 (none) to 5 (severe), resulting in a total score ranging from 0 to 50. The SPIS has high internal consistency (Keuthen et al., 2001a; Snorrason et al., 2013), and scores appear to correlate with duration of picking, satisfaction of picking and shame associated with picking.
The third measure is the Skin Picking Impact Scale-Shorter Version (SPIS-S). The SPIS-S is the shorter version of the SPIS consisting of only a 4-question scale (Snorrason et al., 2013). The SPIS and the SPIS-S have a similar factor structure and both have high internal consistency. These measures assess the impacts of picking behaviors on social life, perceived embarrassment associated with picking behaviors, consequences of picking behaviors and perception of attractiveness (Snorrason et al., 2013). The ultimate difference between the two scales is the brevity of the shorter version measure as compared to 10 items on the other measure. Snorrason and associates (2013) found acceptable discriminant and convergent validity for the SPIS and the SPIS-S; both measures may be considered for clinical use.
The Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS) is another skin picking assessment measure (Walther, Flessner, Conelea, & Woods, 2009). The MIDAS consists of 21 items and highlights the degree of focused picking (e.g., body sensations, reaction to negative emotions) and automatic picking behaviors (e.g., unaware of skin picking behaviors, concentrating on another activity, unintentional picking; Walther et al., 2009). Within the measure, each item is rated on a 5-point scale (i.e., 1–5; not true of my skin picking to always true for my skin picking), and a specific score is provided for focused and automatic picking. The MIDAS demonstrates adequate internal consistency and good validity (i.e., construct and discriminant), making it a reliable and valid measure for distinguishing types of skin picking behaviors (Walther et al., 2009). This assessment is especially useful in facilitating an understanding of the client’s motivations for skin picking, as well as potential ways to reduce the problematic behaviors.
The Skin Picking Impact Survey (SKIS; Tucker, Woods, Flessner, Franklin, & Franklin, 2011) is a self-report survey measure. The SKIS, which consists of 92 items, is used to explore multiple dimensions of skin picking behaviors. This survey consists of individual items that assess skin picking symptoms (e.g., presentation), levels of severity (e.g., urges, intensity, time spent, distress, avoidance), consequences (i.e., physical and psychosocial), treatment-seeking history, and demographic information. The SKIS demonstrated acceptable internal consistency (Tucker et al., 2011). Additional items are used to assess for comorbid disorders and other associated symptoms (e.g., depression, anxiety, stress).
Finally, a unique approach to assessing excoriation disorder is to utilize a functional analysis assessment (LaBrot, Dufrene, Ness, & Mitchell, 2014). Although not created primarily to assess skin picking behaviors, a functional analysis assessment is a behavioral technique used to explore the relationship between any stimuli and response (e.g., being cold and shivering; LaBrot et al., 2014). With regards to excoriation disorder, the functional analysis assessment consists of behavior scales and individual interviews with anyone close to the client (e.g., spouse, family member, classroom teacher). The interviews include a discussion of the client’s behaviors and antecedents to such behaviors (LaBrot et al., 2014). This interview also involves a direct observation of the client in the most problematic setting (e.g., home, work, school), and counselors should take note of the time of day or events that often lead up to skin picking behaviors.
A functional analysis assessment also might involve the use of a thought log to help explore thoughts that lead to skin picking behaviors (LaBrot et al., 2014). This connection between thoughts (i.e., obsessions) and behaviors (i.e., compulsions) is characteristic of the obsessive-compulsive DSM-5 classification under which excoriation disorder is housed. Counselors may suggest that clients self-monitor their skin picking behaviors in order to better understand the frequency, triggers, cues, and increases or reductions in thoughts and behaviors. For example, clients may be asked to place a journal or worksheet in places where picking often occurs (e.g., bathroom, bedroom) and then to report and rate the intensity of urges, precipitating events, alternative behaviors, and if picking behaviors actually occurred. When assessing skin picking, clients also should be invited to note any attempts to stop picking, consequences of the skin picking behaviors, and other behaviors that could potentially serve as incompatible replacements (LaBrot et al., 2014). The use of a functional analysis assessment allows the counselor to gain a more complete, contextual picture of the behaviors.
To gain a richer understanding of the client’s behaviors, counselors might (if approved by the client) gather assessment and baseline information from the client’s friends and family members (Grant & Stein, 2014). During the assessment process, counselors should explore all aspects of the client’s life, including recent life experiences, past traumas and current life stressors (LaBrot et al., 2014). An accurate diagnosis and collaborative treatment plan can be developed when this information is integrated to form a contextual understanding of the client’s skin picking experiences.
Diagnosis
A thorough assessment helps counselors to identify an accurate diagnosis. Armed with assessment data, counselors can determine the presence of excoriation disorder and any comorbid disorders. In order to accurately diagnose the disorder, counselors must be familiar with the DSM-5 diagnostic criteria and understand diagnostic considerations related to the disorder.
The onset of excoriation disorder varies significantly, but it most often begins in early adolescence or between the ages of 30 to 45 years old (Grant et al., 2012). Skin picking causes physical harm, and clients often make repeated attempts to reduce the behavior because of the distress and physical impairment it invites. By definition, excoriation disorder is not caused by a substance or medical condition and not accounted for by another disorder (APA, 2013). The diagnostic features of excoriation disorder remain the same regardless of age or other multicultural factors (Grant et al., 2012). The general features that a counselor should look for when diagnosing excoriation disorder include a preoccupation with picking behaviors, difficulty in controlling the behaviors and distress resulting from the behaviors.
Because this is a newer diagnosis, it is often overlooked, misdiagnosed (Grant et al., 2012), or overshadowed by comorbid diagnoses (APA, 2013; Grant & Stein, 2014; Hayes et al., 2009). It is important to distinguish between excoriation disorder and nonsuicidal self-injury, both of which involve self-inflicted damage to the body that provides relief from unwanted thoughts or feelings (APA, 2013). Nonsuicidal self-injury is typically motivated by negative thoughts or feelings about the self in relation to others, and bodily harm provides a feeling of relief or euphoria (APA, 2013; Shapiro, 2008). Conversely, excoriation disorder is an obsessive-compulsive and related disorder and is more ritualistic; unwanted thoughts and feelings are directly related to bumps or certain types of scabs on the body, and clients have a routine related to removal (e.g., examining, picking) and disposal (e.g., playing with or eating) of such bumps or scabs (APA, 2013; Capriotti et al., 2015; Walther et al., 2009).
Individuals with excoriation disorder generally have difficulty resisting the urge to pick and often believe their behavior cannot be altered or changed (Kress & Paylo, 2015). Typically, there are two types of picking behaviors: behaviors that are automatic and behaviors that are focused (Christenson & Mackenzie, 1994). Individuals who engage in picking behavior outside of their awareness, such as while watching television or while reading a book, are engaging in what is known as automatic picking. Those who are fully aware of their behavior and pick to regulate or to manage negative emotions due to specific thoughts or stressors are engaging in focused picking. Both types of picking typically cause client embarrassment, impair functioning and are difficult to manage and control (Odlaug, Chamberlain, & Grant, 2010).
Although focused skin picking might seem to be more directly tied to conscious obsessions than the automatic type, both types were reclassified under obsessive-compulsive and related disorders in the DSM-5 due to the universal obsessive and compulsive features of the disorder; these obsessions and compulsions also are shared with individuals who have trichotillomania (Snorrason, Belleau, & Woods, 2012) and body dysmorphic disorder (Tucker et al., 2011). In each of these disorders, obsessions lead to an overwhelming urge to act upon unhelpful thoughts, which is often followed by a brief sense of relief once the compulsion has been engaged and completed. However, the urge inevitably arises again (despite bodily damage and some potential shame), and the cycle continues.
Ultimately, excoriation disorder is characterized by recurrent and excessive tissue damage that is not better accounted for by nonsuicidal self-injury. Those who have excoriation disorder have difficulty controlling their picking behaviors and experience clinically significant distress or impairment as a result of these behaviors (APA, 2013). Assessment measures can be used in conjunction with the DSM-5 in order to make an accurate diagnosis that can inform clients’ treatment.
Treatment of Excoriation Disorder
Several evidence-based treatment options are available for use in treating those who have excoriation disorder (Kress & Paylo, 2015). Unfortunately, many providers fail to use evidence-based treatment approaches in their work with this population (Tucker et al., 2011). A relatively small number of randomized controlled treatment studies have been conducted on this population; however, the most evidence-based approaches include cognitive behavioral therapy, habit reversal training and pharmacotherapy (Capriotti et al., 2015; Kress & Paylo, 2015).
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is an effective strategy for working with clients who have excoriation disorder (Grant et al., 2012; Schuck, Keijsers, & Rinck, 2011). Schuck et al. (2011) conducted a randomized study of college-age students who reported pathological skin picking; participants were provided four sessions of CBT and compared to those on a waitlist. These researchers observed a significant decrease in psychosocial impact of skin picking, severity of skin picking and perceived strength of skin picking cognitions in the group randomly assigned to the four sessions of CBT. These treatment effects were maintained at a two-month follow-up, thus suggesting that CBT is effective in reducing the severity of symptoms, effect of symptoms and dysfunctional cognitions associated with excoriation disorder.
Practically, CBT for clients with excoriation disorder is focused on using cognitive restructuring to counter dysfunctional thoughts (Schuck et al., 2011). Before engaging in CBT techniques, a counselor should ascertain the nature and location of the picking and provide clients with psychoeducation regarding the etiological and maintenance factors related to their disorder. Socratic questioning is one CBT technique used to help clients recognize their fundamental beliefs and automatic thoughts surrounding skin picking (Kress & Paylo, 2015). When applying this technique, the counselor generates a hypothesis about the client’s thoughts (that lead to skin picking), but leads the client to the information rather than suggesting it. The client is led to insight through a series of questions regarding the topic of interest. For example, the counselor might believe that a client’s skin picking obsessions become stronger when personal and professional obligations become overwhelming. The counselor might ask, “What feelings do you have when picking? What time of day do you typically pick? Are there ever days when you do not pick?” The counselor would use reflections to organize and expand upon the client’s responses until they gain new insight about their thoughts, patterns and beliefs regarding this behavior.
When using CBT, irrational thoughts are examined for validity and replaced with more rational thoughts and behaviors (Kress & Paylo, 2015). For example, an individual tempted to engage in skin picking after an argument with a spouse would challenge the need to pick with more rational thoughts, such as, “Even if I become anxious, I can tolerate the anxiety. Instead of picking, I can clean the house or exercise.” This type of change occurs over a period of time, and counselors and clients should celebrate small victories, such as delayed or reduced skin picking, as the more rational thoughts begin to become more salient.
CBT not only involves cognitive interventions, but also includes behavioral interventions such as homework, preventative measures, activity replacement and relapse prevention (Capriotti et al., 2015; Kress & Paylo, 2015; Schuck et al., 2011). Counselors may assign homework such as CBT thought logs to help clients track picking behaviors. While reviewing the logs in session, counselors can assist clients in developing preventative measures, such as wearing gloves or bandages to hinder skin picking, and activity replacement such as reading a book, cleaning or watching television instead of skin picking. CBT also places a heavy emphasis on relapse prevention, or the preparation to prevent future urges to pick.
Habit Reversal Training
Habit reversal training (HRT) is an effective strategy for working with clients who have excoriation disorder (Capriotti et al., 2015; Grant et al., 2012; Teng, Woods, & Twohig, 2006). HRT is a behavioral approach that involves helping clients gain awareness of their skin picking and then replace the picking with more adaptive behaviors (Grant et al., 2012; Ravindran et al., 2009; Snorrason & Bjorgvinsson, 2012; Teng et al., 2006). The first step of treatment is awareness training, which helps clients who are often unaware of their skin picking to associate factors, such as time of day and specific situations, to skin picking behavior (Teng et al., 2006). To facilitate this awareness, a counselor may point out in-session skin picking behavior. After developing an awareness of antecedent situations (i.e., the situations that precede picking incidents), the counselor and client collaboratively develop a competing response, or another behavior that is inconsistent with skin picking, to substitute for the skin picking behaviors (Teng et al. 2006). An example of an alternative behavior would be clenching one’s fist each time a client notices that he or she is picking. This competing response, which should be one that is easily applicable in a number of situations, diminishes the urge or reduces its intensity.
The next step in HRT is the establishment of a contingency management system or token economy involving rewards and punishments. This type of treatment approach allows the clients’ behaviors to be rewarded as they make successive approximations toward the goal. Rewards and punishments must be meaningful to clients, and they also must be specific and timely. At first, rewards are extrinsic, such as verbal praise or toys with children. As target behaviors are reached (e.g., reduced skin picking), clients begin to access more intrinsic reinforcers (e.g., an increased sense of self-esteem, feelings of belonging within the community/society). Finally, clients are coached to consistently implement these operant conditioning strategies outside of session and to eventually apply them to new behaviors (Capriotti et al., 2015; Teng et al., 2006). The client gradually realizes that skin picking is not a necessary coping skill, as other, more adaptive behaviors can be used to effectively reduce stress.
Teng et al. (2006) conducted a controlled study in which they compared HRT treatment to a waitlist control group. These researchers demonstrated a significant reduction in skin picking behaviors at the termination of treatment and upon follow-up assessment, as compared to the control group. The research on HRT suggests that it is a promising approach for use with those who have excoriation disorder.
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT), when used in conjunction with HRT, demonstrates clinical promise in treating those who have excoriation disorder (Capriotti et al., 2015; Flessner, Busch, Heideman, & Woods, 2008). Capriotti et al. (2015), through the use of multiple clinical case studies, demonstrated that Acceptance-Enhanced Behavioral Therapy (i.e., ACT plus HRT) decreased excoriation symptomology in three of four participants in their case study research. These results support the findings of a similar case study done by Flessner et al. (2008), which demonstrated decreased symptomatology of excoriation disorder when ACT was incorporated with HRT.
ACT uses mindfulness techniques to teach acceptance of negative thoughts and emotions and then combines behavior-change techniques to address unhealthy behaviors (Flessner et al., 2008). Initially, the counselor helps the client investigate previous attempts to curb skin picking behaviors (such as avoidance or relaxation while picking). Then, the client and counselor work to distinguish between urges to pick (i.e., thoughts, feelings, sensations) and actual skin picking, emphasizing that even if urges are acted upon, they will soon return. As such, the focus is on increased distress tolerance and acceptance of urges (Kress & Paylo, 2015). The difficulty of controlling urges can be illustrated through metaphors in which the client gains control and a position of power over an undesirable, yet steadfast external circumstance (e.g., working is unavoidable, but you can find a job you enjoy).
Next, using ACT treatment, the client’s ability to control his or her own thoughts and behaviors is highlighted. This emphasis on controlling behavior stands in contrast to most clients’ natural inclination to focus on controlling or avoiding external situations. Next, the counselor and client work to modify and change the thoughts and feelings associated with urges to pick (Flessner et al., 2008). The client and counselor address six processes that contribute to healthy, flexible living: present-moment awareness; acceptance (as opposed to avoidance); nonjudgmental awareness of one’s thoughts; values clarification; changing, rather than reducing, unhelpful thoughts; and short- and long-term behavioral goals. Lastly, treatment progress is reviewed, and the client and counselor engage in relapse management (Flessner et al., 2008; Twohig, Hayes, & Masuda, 2006). Counselors also can integrate medication management when therapeutically indicated.
Pharmacotherapy
If pharmacotherapy is used to treat excoriation disorder, it should be used in conjunction with counseling; medication can control physical symptoms, but contributing mental health factors must be addressed in order to holistically help the client make enduring behavior changes (Grant et al., 2012). Selective serotonin reuptake inhibitors, specifically Fluoxetine (Prozac), have been shown to be effective in treating excoriation disorder and other BFRB (Grant et al., 2012; Simeon et al., 1997). However, this effect has not been consistent across clients (Grant & Odlaug, 2009). Therefore, additional research on the effectiveness of medication is needed. Counselors should provide intentional treatments for clients while taking into account unique client considerations.
Special Considerations
Although those with excoriation disorder might go to great efforts to conceal their wounds from others (Grant & Odlaug, 2009), they are likely to admit to skin picking behaviors when effectively questioned by a mental health professional (APA, 2013). It is important to ensure the clients with excoriation disorder are physically well (i.e., free from medical complications associated with picking), and a referral to medical professionals to ensure physical safety and appropriate medical care may be necessary (Grant et al., 2012).
Excoriation disorder occurs more often in those who also have OCD (APA, 2013). Several additional disorders are often found to be comorbid with excoriation disorder, including trichotillomania, major depressive disorder, anxiety, psychotic disorders, neurodevelopmental disorders and factitious disorder (APA, 2013; Hayes et al., 2009). Picking behaviors also could be due to a general medical condition or substance use (e.g., such as with methamphetamine addictions), and these should be ruled out (APA, 2013).
Those with first-degree family members who have excoriation disorder are more likely to also develop skin picking behaviors (APA, 2013). However, skin picking often begins during puberty, and the onset is often associated with the development of skin irregularities (e.g., acne; APA, 2013, Tucker et al., 2011). It was found that approximately 87% of college-aged students in Turkey who had acne or other skin blemishes displayed some skin picking behaviors, but only about 2% reported clinically-significant symptoms of excoriation disorder (Calikusu, Kucukgoncu, Tecer, & Bestepe, 2012). The aforementioned finding suggests that dermatological factors, such as acne, might explain the onset of excoriation disorder, but not necessarily the maintenance of such behaviors. As such, family history of such behaviors should be considered by counselors when assessing and treating this disorder.
Collaborative relationships with other professionals can be helpful when working with a client who has excoriation disorder. If clients are provided with psychopharmaceutical interventions, counselors should take care to communicate with the prescribing physician in order to help the client maintain proper medication schedules and to potentially provide psychoeducational support to the client (Grant et al., 2012). Although consultation with a dermatologist is not always necessary, this valuable resource should be integrated into treatment when possible, and open communication can ensure that clients are receiving the support that they need (Calikusu et al., 2012; Grant et al., 2012).
Finally, although excoriation disorder is now an official DSM diagnosis, the research literature on effective treatments is still in its infancy stage (Capriotti et al., 2015). Additional research also is needed to determine the prognosis of excoriation disorder. As previously indicated, researchers have found psychopharmaceutical and cognitive behavioral interventions to be promising (Flessner et al., 2008; Grant et al., 2012; Schuck, et al., 2011; Simeon et al., 1997), but additional outcome research still needs to be conducted on this disorder (Capriotti et al., 2015). Further research on this new DSM-5 disorder will provide more concrete information regarding assessment and treatment options for this population.
Summary
The etiology of excoriation disorder is still being explored, and several theories are currently supported as viable options. Both biological and psychological factors appear to contribute to the development and maintenance of this disorder (Grant et al., 2012). Skin picking behaviors are often found in those who have higher levels of emotional impulsivity, and these behaviors might serve as a way for individuals to regulate their emotions.
There are several formal measures that can be used to aid in the assessment and diagnosis of excoriation disorder. In addition to formal quantitative measures, the functional analysis assessment is a helpful method that can be used to increase both the client’s and the counselor’s understanding of the behaviors (LaBrot et al., 2014). Regardless of the assessment procedures employed, counselors should explore all aspects of the client’s life in order to create a comprehensive treatment approach.
Since excoriation disorder is a new diagnosis in the DSM-5, it is often overlooked or misdiagnosed. Counselors should fully assess a client’s presenting concerns in order to determine an accurate and helpful diagnosis. Counselors also should note that this disorder is often comorbid with other mental disorders (APA, 2013; Grant et al., 2011; Hayes et al., 2009).
In terms of the treatment of excoriation disorder, CBT is one of the more evidence-based approaches (Grant et al., 2012; Schuck et al., 2011), as is HRT (Grant et al., 2012; Teng et al., 2006). ACT has been used with success with HRT (Capriotti et al., 2015; Flessner et al., 2008). Psychopharmacotherapy also holds promise as an effective adjunct to psychosocial treatments (Grant et al., 2012; Simeon et al., 1997).
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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Nicole A. Stargell, NCC, is an Assistant Professor at the University of North Carolina at Pembroke. Victoria E. Kress, NCC, is a Professor at Youngstown State University. Matthew J. Paylo is an Associate Professor at Youngstown State University. Alison Zins is a graduate student at Youngstown State University. Correspondence can be addressed to Nicole Stargell, UNC Pembroke, P.O. Box 1510, Department of Educational Leadership and Counseling, 341 Education Building, Pembroke, NC 28372, nicole.stargell@uncp.edu.
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.
Dec 10, 2015 | Article, Volume 5 - Issue 4
Theodore P. Remley, Jr.
TPC Editor Note: Earlier this year I was in the wonderful city of New Orleans and realized it was the 10th anniversary of Hurricane Katrina. In 2005 I was involved with operations at the National Board for Certified Counselors that sent 240 National Certified Counselors to New Orleans and the surrounding area to provide direct crisis counseling and disaster relief. Having done similar work in New York City following the attacks in 2011, I found myself reflecting on what it might be like 10 years later in the Crescent City from a counseling perspective.
Of course I immediately thought to contact Dr. Ted Remley, who was living in New Orleans and teaching in counselor education at the time of the storm. I knew that his personal perspective would be invaluable, leading me to ask him to write this commentary about his reflections on mental health services in New Orleans today. Dr. Remley returned to the city last year to teach in a doctoral program in counselor education and supervision. His many years of experience and astute vision of the global process of counseling have resulted in the following personal analysis. It is my hope that this article is commemorative of the challenges that all mental health workers experienced during and after Hurricane Katrina, and the heroic services they provided during a time of extreme stress and loss. — J. Scott Hinkle, NCC
Ten years after Hurricane Katrina, the counseling profession in New Orleans has changed. The author, along with a group of counseling and other mental health professionals who were providing services at the time of the hurricane and still working in the city 10 years later, provided their impressions of counseling in New Orleans a decade after the storm. The population of New Orleans and the presenting problems of clients shifted after Hurricane Katrina. The residents have required help from counselors, supervisors, counselor educators and agency administrators in order to adapt to new challenges. The need for counselors to possess skills in trauma counseling was one of the lessons learned from the disaster. Agency administrators also advised using caution after a disaster when considering funding offers and research study proposals. While it may be impossible to prepare thoroughly for each unique disaster, Hurricane Katrina taught counseling professionals in New Orleans that after a disaster, flexibility and creativity are required to survive.
Keywords: Hurricane Katrina, mental health, trauma, disaster, counselor educator
Pausing to assess counseling and other mental health services in New Orleans 10 years after Hurricane Katrina has been a worthwhile endeavor. Many people are curious about what has happened to New Orleans since the hurricane, and counselors are particularly interested in how counseling and other mental health services have changed. The unique challenges due to Hurricane Katrina faced by New Orleans counselors who live and work in the city have not been forgotten or put aside since the storm.
The state of counseling and other mental health services in New Orleans a decade after the hurricane are presented in this article along with some of my own observations. This article does not report a qualitative study, but instead offers a summary of the impressions of counseling and other mental health services from a select group of professionals who were providing services at the time of Hurricane Katrina and still working in mental health agencies in New Orleans 10 years later. Rather than presenting only my observations of the state of counseling in New Orleans today, I asked several others to share their impressions and I have attempted to summarize their experiences.
Scholars have examined the aftermath of Hurricane Katrina and studied numerous aspects of the results of the devastating storm (Chan, Lowe, Weber, & Rhodes, 2015; Wang et al., 2007; Weisler, Barbee, & Townsend, 2006). Specific areas of investigation have included a school-based disaster recovery program for children (Walker, 2008), the precipitation of suicide (Kessler, Galea, Jones, & Parker, 2006), the disruption of mental health treatment (Wang et al., 2008), and the differences between people who were displaced and those who returned to New Orleans (Priebe, 2014). Analyses have been completed of leadership in the city (Gohl, Barclay, Vidaurri, Newby, & Arquette, 2015), the restructured education system (Lazarchik, 2015), the social capital and repopulation of New Orleans (Rackin & Weil, 2015), and tourism (Thomas, 2014; Vernet, 2015). Similarly, to obtain an up-close and personal perspective of the changes in counseling and other mental health services, I contacted professionals who were working in mental health agencies in the New Orleans area before or at the time of Hurricane Katrina and were still at a local agency today. These individuals also had a perspective and analysis regarding the effects of the hurricane, having had a major role in the continuation of counseling services at their agencies after the storm. And, like all residents of New Orleans, they also had to rebuild their personal lives following the hurricane.
The Changed City
New Orleans 10 years after Hurricane Katrina is different from the New Orleans that existed in August 2005. While the French Quarter, Uptown and other affluent neighborhoods appear hardly changed, at a deeper level the city is not the same as it was before the hurricane. The most obvious change, aside from the areas where houses are still boarded up and abandoned, is the population. New Orleans now holds 93% of the number of people it had prior to Hurricane Katrina (Shrinath, Mack, & Plyer, 2014). However, it is important to note that for several months after Hurricane Katrina, the city was still covered in floodwaters and had almost no people. Although the population has been reduced by 7%, a number of people living in New Orleans are new to the city. Many residents who lived in New Orleans before Hurricane Katrina did not return. The population loss affected the day-to-day lives of both the people who relocated to other areas of the United States and those who stayed behind and lost contact with relatives, friends and neighbors. Shrinath et al. (2014) provided a review of the changes in the New Orleans population that have occurred since Hurricane Katrina based on data provided by the U.S. Census Bureau. Overall, the population has become smaller, older, more educated and a bit poorer. In addition, New Orleans is now more Hispanic and Caucasian, and less African American.
New Orleans public schools have largely been replaced since Hurricane Katrina with charter schools, which nine out of 10 students now attend (Khadaroo, 2014). Many schools now contract with agencies that provide mental health counseling at school, significantly altering the role of traditional school counselors, and in some cases, replacing them. Today, counselors working as mental health counselors in schools in New Orleans are called upon to diagnose and treat emotional and mental disorders and to be much more involved in family counseling than school counselors were in the past. Consequently, traditional school counselors have been forced to interface with contracted mental health counselors and redefine their roles and responsibilities.
Implications for Counselors and Counselor Educators in New Orleans
One of the facts that counselors learned from Hurricane Katrina is that the demographics of a population will likely change after a disaster (Arendt & Alesch, 2014). Counselors will need to shift from serving one population to another, and will be required to learn new skills. Following a disaster, administrators will need to provide continuing education for counselors so that they can learn new skills, and counselor educators will need to prepare graduate students for work in disaster environments.
Changes in the median age of New Orleans citizens after the hurricane have resulted in an older population, fewer children and more people living alone, which have had a significant impact on counselors providing services in the city today. Counselors with little to no expertise in providing services for elderly, isolated clients have had to be educated on new skills. In fact, many counselors who previously worked with children are now counseling older adults with different needs.
Prior to Hurricane Katrina, few schoolchildren had access to mental health counseling to the extent that they do in today’s charter schools. Counselor educators in New Orleans now prepare counselors who wish to work in schools for both the traditional role of school counselors in parochial or public schools and for the new role of school mental health counselors for those positions in agencies that contract to provide services in charter schools.
Counselors in New Orleans served a population challenged by poverty prior to Hurricane Katrina and continue to provide services to people who are impoverished at a much higher rate than people living in many other areas of the United States. Counseling individuals living in poverty requires special skills in order to serve their needs (Ratts & Pedersen, 2014). As a result, universities in New Orleans are required to prepare their graduates to understand and serve clients of poverty. Moreover, a report issued in the fall of 2012 by The Data Center, an independent research organization in New Orleans, indicated that 37% of the people in New Orleans live in asset poverty, defined as not having enough funds to support a household for 3 months if the main source of income was lost (Shrinath et al., 2014). Asset poverty has particularly severe implications in New Orleans because evacuations from hurricanes are necessary every few years and require funds or credit. Counselors in New Orleans who provide services to poor clients must help their clients prepare for hurricane evacuation despite not having needed financial resources. This narrative is told countless times during each evacuation maneuver.
My Story in Brief
I am a counselor educator and was one of the counseling professionals in New Orleans who chose to relocate after Hurricane Katrina. While such decisions are complicated and are motivated by multiple factors, the primary concerns that led to my departure were that the university where I was working, like all entities in New Orleans, was unstable and experiencing severe financial stress, and I was caring for my elderly mother who needed regular medical attention that was not readily available in the city after the hurricane. I resigned from the university in New Orleans in May 2006, almost a year after the hurricane, and relocated to another state to teach in a counselor education program. I had the opportunity to return to New Orleans eight years later and assumed my current position as a counselor education professor in 2014. When I left New Orleans in 2006, I was sad to be leaving my colleagues and friends, quite apprehensive about my professional future, financially vulnerable, and concerned about health care for my family members as well as myself. When I returned eight years later, I was happy to be returning to my circle of friends, delighted to be welcomed by colleagues, comfortable with my professional future, financially secure, and confident that health care was readily available in New Orleans. When I returned, I found a city that was different in many ways since the hurricane, and a city that also was much the same.
The differences in New Orleans 10 years after Hurricane Katrina, from a personal perspective, were both subtle and striking. After living with my family temporarily in the mountains of Georgia, my return to New Orleans for a visit about two months after the storm was astonishing. Public services were limited. On the other hand, the city was functioning. People were going to work, utilities had been restored, and residents who had returned were doing their best to resume the lives they had known prior to the storm. I experienced many personal challenges, which included repairing my hurricane-damaged home, finding daily care for my elderly mother, and hosting friends for a year who had lost their home in the flood that followed the hurricane. During these challenges, I remained aware and thankful that my burdens were far fewer than those of many of my neighbors, friends and fellow residents.
New Orleans 10 Years Later: My Perspective
My personal impressions of New Orleans 10 years after the storm are generally positive, but there are many scars for those living in the aftermath of the storm. When I returned in 2014, one of my friends who had not left and was still living in the city said, “After Hurricane Katrina, everything changed” (Anonymous, personal communication, August 1, 2014). He said his friends were gone, he no longer had his job, his children and their families had relocated out of state, and everything seemed a mess. His reaction was not unique. Much has been written about the hardships faced by people after Hurricane Katrina, particularly by the poor and uneducated, but many of the stories of professional mental health workers living in the city at the time of the storm have not been told. For the past decade, counselors in New Orleans have been serving the citizens, including counselors who lost their homes in the flood after the storm.
For me, day-to-day life in New Orleans 10 years after Hurricane Katrina appears to be much what it was before the disaster. There is still too much poverty and crime. Although in the French Quarter one can hardly see any differences a decade later, a drive through the Ninth Ward or the community of Lakeview near Lake Pontchartrain shows the devastating aftermath of the hurricane.
Changes in Mental Health Services in New Orleans Since Hurricane Katrina
In an effort to encourage the mental health professionals I contacted to be forthright and free from inhibition in their responses, no individuals or agencies are identified; and because of this degree of privacy, only general information is provided. Mental health professionals who were still working at agencies in New Orleans and responded to my questions included counselors, psychologists and social workers in public and private nonprofit agencies that provide a wide array of counseling and other mental health services to all levels of the population. I was able to obtain informal, personal responses to a series of questions from eight mental health professionals who were working in counseling and other mental health agencies before Hurricane Katrina and are still working in agencies a decade later. The information, perspectives and comments they provided helped paint a picture of mental health services in New Orleans today.
It is telling in itself that I was able to locate only a few mental health professionals who were still working in the same agencies in New Orleans 10 years after Hurricane Katrina. The agencies themselves have changed substantially. Although some have flourished, many have decreased in size and a number have ceased to exist. Staff turnover in New Orleans mental health agencies has been significant. Almost all top-level administration positions are held by different people, mental health practitioners have come and gone, and the number of staff members has generally decreased. I contacted the largest governmental mental health agency in the city in an effort to find a person who had been working there at the time of Hurricane Katrina and was still there. Not one administrator or mental health professional fit the criteria; there had been a 100% staff turnover in the past 10 years.
Agency differences 10 years after the hurricane. When asked to compare and contrast the current circumstances at the agencies with the situation 10 years before, the mental health professionals provided a variety of responses. Most agencies are operating 10 years after the disaster in a fashion similar to what they were doing prior to the hurricane. For an agency to have survived after Hurricane Katrina is, in itself, notable. All agencies were closed for several months during the evacuation of the city and some did not reopen for a significant period of time. In several agencies, as might be expected, the services shifted to dealing with trauma, with two agencies now specializing in trauma recovery. Several professionals reported that counseling and other mental health services after the storm were less often provided by licensed mental health professionals. For example, mental health interns who were completing their degree programs, as well as individuals who had completed their degrees and were working toward licensure, were often providing services. These changes might suggest that the quality of counseling services had been compromised in New Orleans. Certainly counselor educators and counselor supervisors have experienced an added burden of preparing new counselors to hit the road running (i.e., be better prepared to deliver professional counseling services earlier in their careers than what might normally be expected). Counseling supervisors have had to closely monitor the work of neophyte professionals to ensure that counseling services are of high quality.
One counseling agency experienced tremendous growth, morphing from a small agency with three part-time mental health professionals to an agency with over 50 mental health providers who are either licensed or working toward licensure. Such significant growth can test an organization’s capacity to function effectively. Administrators at this agency have been challenged to find and hire competent counselors with the needed expertise to serve the population.
Three agency professionals indicated that they have been more focused on evidence-based mental health practices since Hurricane Katrina. They did not indicate why this change had occurred, but it is notable that such a change did become part of the agencies’ practices. It is likely that governmental and private funding agencies required grant recipients to demonstrate engagement in mental health practices that were evidence-based.
Client needs after the hurricane. Mental health professionals reported significant shifts in the populations that they served prior to Hurricane Katrina and afterward. Several reported that the number of services for individuals suffering from trauma had significantly increased, not only from the hurricane, but also from other types of crises, including sexual trauma and other forms of violence.
One agency professional who served primarily indigent clients indicated a significant rise in the demand for free or reduced-cost services from families in households with incomes below $20,000 per year. At this particular agency, 25% of the clients came from families with incomes between zero and $8,000 per year. At the other extreme, an agency that served a more affluent population had an increase in the number of young adult clients who moved to New Orleans to take jobs assisting in the city’s recovery. Consequently, counselors at agencies have had to adjust to serving clientele they may not have worked with in the past. Agency administrators have had to provide significant in-service training to help counselors adjust to changing client needs.
Mental health professionals reported serving more Hispanic clients and indicated that attention-deficit/hyperactivity disorder and depression and anxiety issues have become more prevalent. Several agency professionals indicated that since Hurricane Katrina, they have served more clients in general, and specifically more children. In addition, some counselors who had never counseled children received in-service education in counseling children and adolescents. Currently, there is a need in the city for counselors who are bilingual and can provide counseling services in Spanish.
Changes in professional-to-client ratios since Hurricane Katrina. Five mental health professionals indicated that their agencies had established a maximum number of clients that each professional could serve in order to ensure that those who were served would receive high quality services. Some agencies established waiting lists and began offering more group services in order to avoid overburdening their professional staff.
Those agencies that had found it financially necessary to decrease their staff had correspondingly decreased the number of clients served. One mental health professional commented that challenges with Medicaid and health insurance reimbursement had made it difficult to afford the number of licensed mental health professionals needed. Agency administrators have had to protect their counselors from stress and burnout as client demand has increased and the number of staff has decreased. Administrators have met this challenge by reducing the number of clients on counselors’ caseloads, establishing waiting lists and offering more group services. The shift to more group services implies that competent group counseling skills and experiences are needed in New Orleans.
Government funding since the hurricane. When asked whether their agencies had received state or federal funding to support them since Hurricane Katrina, most professionals indicated that their agencies had received such funds. Agency administrators reported receiving funds from a local parish government agency that distributes funds from the federal government (specifically, from the U.S. Department of Housing and Urban Development and the Substance Abuse and Mental Health Services Administration). Some agency administrators also reported receiving funding from the American Red Cross, United Way, and local foundations and charities. Three agencies reported receiving Federal Emergency Management Agency funds for operating costs and reconstruction after the hurricane.
How Would Agencies Be Different if Hurricane Katrina Had Not Happened?
Mental health professionals were asked how they believed their agencies would be different today if Hurricane Katrina had not happened. Responses varied. Two mental health professionals said that if the hurricane had not occurred, their agencies would have continued to struggle financially, indicating that the hurricane had brought at least a degree of relief from financial problems. Perhaps the outside funding that flows into an area after a natural disaster can infuse funds into financially struggling counseling agencies, allowing them to continue to operate when they might not have been able to do so if the disaster had not occurred.
Several mental health professionals reported that because of Hurricane Katrina, agency personnel had learned a great deal and certainly would be able to handle any similar type of natural disaster in a better fashion if one should occur in the future. Today’s counseling graduate students are being taught disaster, crisis and emergency response counseling procedures, as required by the Council for Accreditation of Counseling and Related Educational Programs (2009) in their counselor preparation curriculum. However, most counselors completed their graduate training prior to the time that these standards were implemented, requiring in-service training in post-disaster operations.
Most agency personnel reported that their agencies had benefitted from having experienced Hurricane Katrina. One mental health professional indicated that if not for the hurricane, the agency would not have a close relationship with area schools, would lack evidence-based practices devoted to psychological trauma, and would be wanting in innovation and creativity. Another said that the agency would not have grown as much. Two mental health professionals suggested that Hurricane Katrina had provided their agencies with national attention that allowed the agencies to become leaders in their areas of specialization, which included juvenile justice and trauma. One mental health professional said that without the hurricane, the agency would not have been tested or trained in the following areas: crisis management, grief and loss due to a natural disaster, management of post-traumatic stress disorder, and how to counsel when the counselor is experiencing similar stressors. Lastly, another counseling professional indicated that staff would not have received trauma recovery training if Hurricane Katrina had not occurred.
Recommendations for Mental Health Agencies
Mental health professionals who provided information for my personal analysis offered recommendations for counselors who must contend with a disaster. They also gave recommendations to agency personnel for preparing for a disaster.
Recommendations on Contending With a Disaster
Three mental health professionals suggested that perhaps preparing for specific disasters is impossible, while there was agreement that agencies should be prepared to deal with emotional trauma in the event of a natural disaster. Two mental health professionals suggested that planning for the possibility of a disaster would most likely not be productive. One mental health professional said that “preparing for the next disaster based on experiences from Hurricane Katrina would be like preparing for the next war based on experiences from the last one.” This mental health professional added that all disasters are unique and that it would do no good to base disaster recovery plans on what New Orleans experienced as a result of Hurricane Katrina. Another mental health professional emphasized that being flexible is essential, so that programs can be developed to meet the needs of the community.
Although no amount of disaster preparation can help counseling agencies prepare for all possible challenges, perhaps the best response to disasters is to be flexible, creative and practical, taking on each problem as it is encountered. One mental health professional cautioned that agencies should be prepared not only to treat clients with post-traumatic stress disorder resulting from the disaster, but also to treat trauma symptoms that stem from unresolved trauma from childhood or past life experiences that surface after the newer trauma caused by a recent disaster. The concept that mental health agencies should always be prepared to deal with the trauma that follows a natural disaster was universally voiced by mental health professionals. In addition, self-care for counselors has become a popular topic in the professional literature (Alvarez, 2015; Ohrt & Cunningham, 2012; Thompson, Frick, & Trice-Black, 2011; Witt & McNichols, 2014), and mental health workers in New Orleans emphasized assessment of trauma among counselors for up to two years after a disaster.
The most significant disagreement among mental health professionals concerned whether it is advisable to join in collaborative efforts or partnerships with other agencies after a disaster. While one mental health professional said that collaboration is a key to recovery, and two counselors supported this idea, another mental health professional said that collaborative partnerships have the potential to support incompetence and ruin inter-organizational relationships. A third mental health professional warned that mental health agencies should not chase or accept time-limited funding after a disaster, and should not expand services based on funding that will soon disappear.
One mental health professional indicated that collaboration was touted as the best recovery tool by many after Hurricane Katrina and acknowledged that the concept of collaboration after a disaster could be a win-win for organizations leveraging their collective expertise into post-disaster response and recovery. This mental health professional said that organizations outside the community often want to create a collaborative partnership after a disaster by providing trauma intervention or counselors for a local agency at no cost. However, such offers could possibly be exploitive. Often the intervention offered is not evidence-based, and the outside organization wants to use the agency as a way to increase its own credibility or perhaps raise funds because its employees are responding to the needs of the community after a disaster. Furthermore, this mental health professional warned that university professors who want to conduct research are often more interested in increasing their scholarship productivity than helping a mental health agency recover from a disaster. Counselor educators should of course avoid exploiting disaster situations for the sole purpose of increasing their research publications. Counseling agency administrators need to be cautious after a disaster when they are approached about participating in proposed research or service projects.
One mental health professional gave the following advice regarding response to outside organizations or individuals who want to help after a disaster:
I would create collaboratives that are measured in three or six month intervals when every party can check in and decide if the partnership is still working for them. The more difficult questions can come when one of the collaborative partners is not working to their potential, or is undermining the project unintentionally or intentionally. These are often ugly and very difficult situations to solve, and I don’t have much advice on these situations other than to be transparent and honest and to communicate your concerns with leadership when you see these situations on the horizon. (Anonymous, personal communication, May 28, 2015)
This mental health professional suggested asking hard questions of potential collaborative partners, including, “What’s in it for you? What’s in it for us? How long will you be around? What’s your long-term plan after one or two years? How do we continue this after you are gone? How will your success be measured? Who do you report to and what’s their expectation of this collaborative?”
Recommendations on Preparing for a Disaster
Mental health professionals offered a host of general and specific recommendations regarding how agencies should prepare to face a disaster like Hurricane Katrina in the event that such a disaster should occur. General recommendations included ensuring that an agency is well-managed before a disaster if it is to survive the aftermath. Mental health agencies need to develop strong collaborative relationships with other agencies prior to an emergency. Putting into place evidence-based mental health practices provides a strong foundation for moving forward after a disaster. Staff members need to be flexible in their problem-solving because a culture of flexibility, in contrast to rigidity, helps agencies survive disasters.
Specific advice regarding preparing to survive a disaster such as Hurricane Katrina included the following: create an inventory of equipment to help report losses; operate within financial limitations; create a disaster plan that includes specific actions for before, during and after the disaster; create electronic records and have a server outside the area of operation; cross-train office staff; create and test a disaster communication plan; employ a staff grant writer; and create emergency plans for clients. This advice should be beneficial to counselor educators who teach classes in which disaster counseling topics are addressed.
Conclusions
After reviewing the demographics of New Orleans 10 years after the hurricane and communicating with eight mental health professionals who were working in the city prior to the hurricane, I offer the following observations. Overall, most mental health agencies have maintained the level of services they were providing before Hurricane Katrina, although some have actually expanded. Before Hurricane Katrina, there were not enough counseling and other mental health services for poor and middle-class families in New Orleans, and the same situation continues to exist 10 years after the storm.
A focus and specialty has emerged in most mental health agencies in New Orleans since Hurricane Katrina around issues of trauma. Consequently, the study of trauma has become quite popular in the professional literature (see Alvarez, 2009; Brown-Rice, 2013; Buss, Warren, & Horton, 2015; Cohen et al., 2009; Fernandez & Short, 2014; Hudspeth, 2015; Jones & Cureton, 2014; Jaycox et al., 2010; Langley et al., 2013; Parker & Henfield, 2012; Tosone, Bauwens, & Glassman, 2014). As one mental health professional pointed out, a natural disaster not only precipitates the distress resulting from the crisis experiences, but also brings unresolved prior trauma to the surface for many clients. Since trauma is likely to be a significant focus of mental health agencies after a disaster, disaster preparedness plans should include the education of all staff members on counseling trauma victims.
It appears that mental health agency personnel in other locations who want to learn from the experiences of practitioners who dealt with the aftermath of Hurricane Katrina in New Orleans should consider the advice given by several mental health professionals with whom I communicated—prepare to be flexible in case disaster occurs. Perhaps counselors and administrators who have leadership skills that include creativity and flexibility would be ideal for agencies after disasters have occurred, as opposed to those who have a high need for structure or who have trouble operating without clear procedural guidelines. \
While partnerships and collaborative arrangements have the potential for helping mental health agencies survive and even prosper after a disaster, such arrangements should be evaluated carefully prior to agreement. Leaders in one of the New Orleans agencies attributed their growth and expansion to collaborative relationships and partnerships. However, several other mental health professionals appeared to have had negative experiences with collaborative arrangements and recommended that such offers be viewed with caution. Accepting time-limited financial support also can lead to problems if agencies expand their services based on temporary support and must then scale back after financial resources disappear.
The most important lesson I learned from interviewing agency administrators in New Orleans who have been at their agencies for the 10 years since Hurricane Katrina was that it would have been impossible to prepare for the aftermath of the storm. As a result, it is important after a disaster for counselors and administrators to assess their unique situation, determine what counseling services are needed, provide in-service training when necessary, avoid relying on short-term funding to plan for the future, and pay attention to the self-care of counselors. New Orleans is unique and Hurricane Katrina’s flooding of the city was a unique event. Several mental health professionals indicated that assessing the needs of the community after the storm and responding to those needs, as well as caring for the well-being of their employees, were critical aspects of their successful survival.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Dec 9, 2015 | Article, Volume 5 - Issue 4
Lindsey Mitchell
The purpose of this study was to explore the relationship of five variables—primary appraisal, secondary appraisal, coping skills, social support and stigma—to bereavement among women whose military spouses had completed suicide. Four correlations to bereavement (primary appraisal, secondary appraisal, coping skills and stigma) were significant. Hierarchical multiple regression analysis assessed the overall relationship of bereavement (the criterion variable) to the five predictor variables, along with the unique contribution of each predictor variable. In the regression, five of six models (all except Model 4) showed significance. The dissertation on which this manuscript is based has the following practical implications: statistically significant correlations between bereavement and constructs of Lazarus’ Cognitive Model of Stress (LCMS), as well as the significance of Lazarus’ construct of primary appraisal within Model 6, indicate that LCMS holds promise for understanding symptoms of bereavement in women whose military spouses have completed suicide.
Keywords: suicide, bereavement, military, spouse, Lazarus
Reports indicate that suicides in the U.S. military surged to a record number of 349 in 2013. This figure far exceeds the 295 American combat deaths in Afghanistan in 2012 and compares with the 201 military suicides in 2011 (National Institute of Mental Health [NIMH], 2013). Some private experts predict that the trend will worsen this year (Miles, 2010).
From 2008–2010, the Army reported the highest number of suicides (n = 182) among active duty troops; whereas the Navy and Air Force reported 60 and 59 respectively (National Institute of Mental Health [NIMH], 2013). The Marine Corps had the largest percentage increase in suicides in a period of 2 years (Lamorie, 2011). U.S. veterans accounted for 20% of the more than 30,000 suicide deaths in the United States in 2009. Between 2003 and 2009, approximately 6,000 veterans committed suicide annually, an average of 18 suicides each day (Congressional Quarterly, 2010; Miles, 2010). During the 2009 fiscal year, 707 members of the veteran population committed suicide, and another 10,665 made unsuccessful suicide attempts (Miles, 2010). Certain experiences of military service members (e.g., exposure to violence, act of killing the enemy, risk of injury, exposure to trauma) increase suicidal tendencies (Zamorski, 2011).
For every person who completes suicide, an estimated 20 people experience trauma related to the death (NIMH, 2010). This suggests that from the 349 military suicides in 2013, approximately 7,000 people have experienced related trauma. Suicide survivors are family members and friends whose lives significantly change because of the suicide of a loved one (Andriessen, 2009; Jordan & McIntosh, 2011; McIntosh, 1993). Survivors of suicide may have higher risk for a variety of psychological complications, including elevated rates of complicated grief and even reactive suicide (Agerbo, 2005).
It is also important to note that suicide survivors might not differ significantly from other bereaved groups regarding general mental health, depression, post-traumatic stress disorder symptoms and anxiety (Sveen & Walby, 2008). Examining the impact of suicide on surviving military family members may provide important information on minimizing negative consequences, including possible survivor suicide.
Military deaths are often sudden, unexpected, traumatic and/or violent in nature, and the family is conditioned to anticipate these types of deaths. In contrast, death by suicide is not anticipated and might not be handled well among military families (Martin, Ghahramanlou-Holloway, Lou, & Tucciarone, 2009). Suicide within the military culture is a traumatic as well as a unique experience. Service members and their families struggle with the visible and invisible wounds of war and the aftermath that combat deaths leave for the survivors. When a service member’s trauma leads to suicide, the military community is less trained and conditioned to process the grief than when death occurs as a direct result of military service (Zhang & Jia, 2009).
Stress plays a role in the grief process within the military culture when it relates to suicide. The chief identifying feature of military culture is warfare, which in turn leads to the claiming of human lives (Siebrecht, 2011). Siebrecht argued that bereavement can only be overcome if people adopt a more rational attitude and grant death its natural place in life. Association with the military ensures that most families will have to experience some form of bereavement and many forms of loss during times of war (Audoin-Rouzeau & Becker, 2002). Military men and woman are less equipped than the general population when it comes to their culture’s acceptance of outward demonstration or sharing of the emotional experience of grief (Doka, 2005).
Stigma
Historically, the stigma of suicide has been present in society (Cvinar, 2005). The biggest obstacles that families with members who have completed suicide confront are acts of informal social disapproval. The surviving family may be suspected of being partly blameworthy in a suicide death and consequently may be subjected to informal isolation and shunning (Bleed, 2007). The stigma of suicide can be subtle. It can be manifested in overt actions taken against the survivors (i.e., placing blame on the family), as well as by omitted actions (i.e., not receiving life insurance), which are probably far more common. When people experience the untimely loss of a family member, there can be feelings of being offended, wounded or abandoned (Neimeyer & Jordan, 2002). The stigmatization experienced by survivors may complicate their bereavement process (Cvinar, 2005; Jordan, 2001; McIntosh, 1993). This complexity results in communication issues, social isolation, projection of guilt, blaming of others and scapegoating (Harwood, Hawton, Hope, & Jacoby, 2002; Lindemann & Greer, 1953). There is a lack of research in the professional literature addressing the grief of surviving military family members impacted by the death, including suicide, of a loved one (Lamorie, 2011).
Suicide and Bereavement
Jordan (2001) researched suicide bereavement and concluded that there are several underlying reasons that it differs from other types of mourning. Jordan summarized that “there is considerable evidence that suicide survivors are viewed more negatively by others and by themselves” (p. 93) and that suicide “is distinct in three significant ways: the thematic content of grief, the social processes surrounding the survivor, and the impact suicide has on family systems” (p. 91). In reviewing the social processes surrounding suicide, Jordan’s analysis supports those of Worden (1991) and Ness and Pfeffer (1990), saying that “there is considerable evidence that survivors feel more isolated and stigmatized than other mourners, and may be viewed more negatively by others in their social network” (p. 93). Most traumatic death survivors will face questions regarding their own culpability in their loved one’s decision to take his or her own life. Survivors may find themselves repeatedly pondering missed warning signs and risk factors (Parrish & Tunkle, 2005). Four primary factors that distinguish the complexities of suicide bereavement for families include stigma, questions about reasons, issues of remorse and guilt, and various logistical and legal factors unique to suicide that necessarily influence the events and processes following death (Minois,1999). The question of why often comes up given the pervasive sense that suicide is a preventable event. This line of thought can often define the grief process. Combined with factors of shock from the sudden, often violent nature of the death, these questions are virtually unavoidable. In some cases, answers to questions of why may never be forthcoming or satisfactory (Steel, Dunlavy, Stillman, & Pape, 2011). Among military families, bereavement is complex. A military death often has circumstances not normally found in the civilian world. It is most likely unexpected, potentially traumatic, occurring in another country, publicized by the media, and enveloped in the commitment to duty and country. Surviving family members of military personnel are often parents, siblings, grandparents and spouses. Military widows are young, often with young families, and are living at a duty station, far away from family and longtime friends (Katzenell, Ash, Tapia, Campino, & Glassberg, 2012).
Bereavement in the Military Culture
Bereavement is a part of the military culture but is often misinterpreted as a weakness that will elicit limited outside support. Military men and women in general are uninformed about the cultural acceptability of outwardly demonstrating their grief or sharing the emotional experience of the loss (Doka, 2005). Although traditional mental health treatments predominantly encourage emotional vulnerability, the military culture values emotional toughness (Kang, Natelson, Mahan, Lee, & Murphy, 2003) and stigmatizes mental illness (Doka, 2005). These attitudes can often deter service members from seeking assistance that could help them to overcome physical and mental health issues. Military culture affects the impact of suicide on families. Each spouse and family has a different bereavement process, and this process is influenced by stigma, social support and ability to cope. In the U.S. military, these issues can be a hindrance to seeking services and can lead to feelings of isolation, which in turn are a risk factor for suicide (Christensen & Yaffe, 2012).
Conceptual Framework
The conceptual framework of Lazarus’ Cognitive Model of Stress (LCMS) was used to frame this study. The underlying construct of this model states that times of uncertainty and difficulty may assist in understanding a person’s ability and capacity to cope with the suicide of a loved one. In general, when people encounter a difficult situation, they employ strategies for dealing with and lessening perceived stress (Groomes & Leahy, 2002).
LCMS (Lazarus & Folkman, 1984) has served as a useful lens for examining the interaction between a person and situational demands. Burton, Farley, and Rhea (2009) used LCMS to frame a study of the relationship between level of perceived stress and extent of physical symptoms of stress, or somatization, among spouses of deployed versus non-deployed servicemen. Eberhardt and associates (2006) examined Lazarus and Folkman’s 1984 stress theory regarding the ways that stress mediators and perceived social support may affect anxiety (as a stress response). The above studies show the usefulness of LCMS in depicting the impact of stress and coping on perceived anxiety, acceptance, ability to lead mentally and physically satisfactory lives, and perception of social support.
LCMS includes primary appraisal, secondary appraisal, coping and perceived social support. Stress is defined as a person’s relationship to his or her environment, specifically a relationship that the person perceives as exceeding his or her resources and endangering well-being. This model supports that the person and the environment are in a dynamic, reciprocal and multidimensional relationship. This conceptualization suggests that people’s perception of stress is related to the way they evaluate, appraise and cope with difficulties.
Stress can be measured by the way an individual appraises a specific encounter. Lazarus and Folkman (1984) presented two types of appraisal. The first is primary appraisal, defined as an individual’s expressed concern in terms of harm, loss, threat or challenge. Harm and loss appraisals refer to loss or damage that has already taken place; threat appraisal refers to harm or loss that has not yet occurred (i.e., anticipatory loss); and challenge appraisal refers to the opportunity for mastery or growth (Lazarus & Folkman, 1984). The second type is secondary appraisal, defined as the focus on what the individual can do to overcome or prevent harm. Lazarus and Folkman suggested that an appraisal of threat is associated with coping resources that can mediate the relationship between stressful events (e.g., loss of spouse to suicide) and outcomes (e.g., ability to seek mental health services).
Coping resources are the personal factors that people use to help them manage situations that are appraised as stressful (Lazarus & Folkman, 1984). Coping resources can be available to the person during the grief process or can be obtained as needed. This fact suggests that the grief process following a suicide is stressful and imposes demands on coping as the bereavement process evolves. Lazarus and Folkman (1984) defined coping as “constantly changing cognitive and behavioral efforts to manage specific external or internal demands that are appraised as exceeding the resources of the person” (p. 141). Coping is a dynamic process that is called into action whenever people are faced with a situation that requires them to engage in some special effort to manage that situation (Lazarus & Folkman, 1984). The ability to cope impacts a person’s bereavement process, and the ways and ability to cope vary with each individual. Stigma and the amount of perceived social support also influence the ability to cope (Bandura, 1997). These variables impact the bereavement process, especially with the added variable of death by suicide.
Social support can strengthen an individual’s position against the stressor and reduce the level of threat (Lazarus, 1996). Research suggests there are specific reasons why survivors do not seek out social support. McMenamy, Jordan, and Mitchell (2008) identified depression and a lack of energy as substantial barriers to obtaining social support.
People who experience a traumatic event are more likely to perceive barriers and not request medical and mental health services due to this lack of energy, lack of trust in professionals and depression (Amaya-Jackson et al., 1999). Provini, Everett, and Pfeffer (2000) stated that the stigma and social isolation that survivors experience can interfere with seeking social support and the willingness of social support networks to come to the aid of the survivor. A lack of social support can increase depression, a lack of energy to complete daily tasks and isolation. Limited social support is especially common for suicide survivors. Shame and guilt surrounding a suicide can impact survivors’ ability to seek social support; however, high social support can be linked to positive mental health.
Barriers to Bereavement
Many suicide survivors struggle with questions about the meaning of life and death, report feeling more isolated and stigmatized, and have greater feelings of abandonment and anger compared with other sudden death survivors (Callahan, 2000). Moreover, the feeling of relief from no longer having to worry about the deceased may distinguish survivors of suicide from survivors of other types of sudden death (Jordan, 2001). Experiencing suicide in one’s family increases risks for family members’ mental health and family relationships (Jordan, 2001). Despite the frequency of suicide, there is limited research focusing on the needs of surviving spouses (Miers, Abbott, & Springer, 2012).
The family system in which the spouses existed as a couple is destabilized by suicide, but the survivor must continue to function. Tasks that were carried out in the relationship must now be carried out by the survivor (Murray, Terry, Vance, Battistutta, & Connolly, 2000). Cerel, Jordan, and Duberstein (2008) stated that because suicide occurs within families, the focus on the aftermath of suicide within families and the impact on the spouse are important areas to investigate in order to determine exactly how to help survivors. Helping survivors to address practical, economic and legal issues, in addition to providing information and therapeutic intervention, is important (Dyregrov, 2002; Provini et al., 2000).
Purpose of the Study
Because of the frequency of suicide in the United States, the increased number of suicides within the U.S. military, and the impact of suicide on the family, the bereavement process among female spousal survivors of military suicides deserves further exploration. The purpose of this study was to explore bereavement in female spousal survivors of military suicides. Using LCMS, the study explored the relationship of bereavement and stigma, social support, primary appraisal, secondary appraisal, and coping skills among women whose military spouse had completed suicide.
Summary of the Study and Methodology
This study investigated the linear relationship between the dependent variable of bereavement and each of five independent variables—primary appraisal, secondary appraisal, coping skills, perceived social support and stigma—among women whose military spouses had completed suicide. The following hypotheses guided the study. Hypothesis 1 stated that there would be a relationship between bereavement and stigma; this positive relationship was significant. Hypothesis 2 stated that there would be a relationship between bereavement and social support; the relationship was not statistically significant. Hypothesis 3 stated that there would be a relationship between bereavement and primary appraisal; this positive relationship was significant. Hypothesis 4 stated that there would be a relationship between bereavement and secondary appraisal; this negative relationship was significant. Hypothesis 5 stated that there would be a relationship between bereavement and coping skills; this negative relationship was significant.
Using hierarchical regression analysis, the researcher examined the relationship of five independent variables—primary appraisal, secondary appraisal, coping skills, social support and stigma—to bereavement. The relationship was statistically significant. The model was a good fit and controlled for time since death (i.e., number of years since the person completed suicide). Therefore, for this sample, the five independent variables are components of a statistically significant model.
Participants and Recruitment
The participants in this study were women aged 18 and older who had lost a military spouse to suicide. Criteria for inclusion were that (a) the service member who had completed suicide had been either on active duty or of veteran status, (b) the survivor was female and 18 years of age or older, and (c) the survivor was considered a spouse. A spouse was defined as legally married to another person or living and cohabiting with another person in a marriage-like relationship, including a marriage-like relationship between persons of the same gender. Participants were chosen from seven national organizations serving veterans. The researcher recruited participants from these organizations by explaining the study and asking for volunteers. The director or assistant director of each organization distributed study information and materials through listservs and posted them on their Web sites. Once prospective participants received an e-mail, they decided whether they wanted to participate and whether they met the eligibility requirements. If the spouses decided to participate in the study, they would complete the survey through Survey Monkey.
Variables
Demographic variables included age, race/ethnicity, length of relationship with the deceased partner, the decedent’s military status (active or retired), the decedent’s length of service, and time elapsed since death. The survey also asked about the deceased’s rank, education level, surviving children and prior suicide attempts.
A self-report online survey was constructed using the following five instruments: the Core Bereavement Items (CBI; Holland, Futterman, Thompson, Moran, & Gallagher-Thompson, 2013), the Stigma of Suicide and Suicide Survivor Scale (STOSASS; Scocco, Castriotta, Toffol, & Preti, 2012), the Coping Self-Efficacy Scale (CSES; Chesney, Neilands, Chambers, Taylor, & Folkman, 2006), the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, 1988), and the Stress Appraisal Measure (SAM; Peacock & Wong, 1990). The SAM is one measure. However, the variables of primary stress appraisal and secondary stress appraisal within it were separated, and the questions within the SAM regarding primary stress appraisal were referred to as the primary stress appraisal measure (PSAM), and the remaining questions of the SAM were referred to as the secondary stress appraisal measure (SSAM). In addition to these assessments, participants would also answer 11 demographic questions and three open-ended questions. The survey was split into seven sections.
The first section had 11 demographic questions. The second section, comprised of the MSPSS, had 12 questions regarding social support of the participant and used a 7-point Likert scale. The third section, comprised of the CBI, had 26 questions regarding the participant’s ability to cope and used a 10-point Likert scale. The fourth section, comprised of the SAM, had 19 questions regarding participant’s stress appraisal measures and used a 4-point Likert scale. The fifth section, comprised of the STOSASS, had 17 questions regarding the participant’s perceived stigma and used a 4-point Likert scale. The sixth section, comprised of the CBI, had 17 questions regarding the participant’s bereavement process and used a 4-point Likert scale. The survey included the three following open-ended questions that were derived from the Grief Evaluation Measure (GEM) and reviewed by three licensed professional counselors working in the field of suicide bereavement: (1) What do you recall about how you responded to the death of your spouse at the time?; (2) What was the most painful part of the experience to you?; and (3) How has this experience affected your view of yourself or your view of your world? To analyze the qualitative responses, the researcher identified the most commonly recurring words or phrases used by participants for each question. Three experts in the field of grief and loss were consulted and confirmed the content and face validity of the survey.
Data Analysis
The Statistical Package for the Social Sciences (SPSS), a statistical software package, generated all of the statistics for this research investigation. A Pearson correlation analysis was conducted to determine whether there was a linear relationship between primary appraisal, secondary appraisal, social support, coping skills, stigma and bereavement for women whose military spouse had completed suicide. Following this analysis, a multiple regression was used to describe the relationships of the independent or predictor variables to the dependent or criterion variable (Lussier & Sonfield, 2004). Because LCMS states that it is possible to discern the order in which a person experiences each variable with regard to a particular event, the variables were entered into the regression using the following equation: Bereavement = {time since death} + {primary appraisal} + {secondary appraisal} + {coping skills} + {perceived social support} + {perceived stigma}.
Results
Descriptive Statistics
Descriptive statistics provided simple summaries of the demographic characteristics of the sample, as well as descriptors such as means and standard deviations for these characteristics. The sample was a well-educated, racially diverse group of women who had lost their military spouses to suicide. The majority of participants were non-Hispanic White females who had attended at least some college. Most were affiliated with the Army and had been married to the military member who had completed suicide. The majority of the partners had committed suicide while on active duty. The mean age of respondents was 33.48 years (SD = 5.20; SE = .373); their ages ranged from 23–50 years. The mean number of children aged 17 or under that were a product of the relationship with the service member was 1.12 (SD = .79; SE = .064); the range was 0–4 children. The mean number of prior suicide attempts by the service member (known/confirmed by the surviving female spouse) was 1.31 (SD = 1.06; SE = .096); the range was 0–4 prior suicide attempts.
Correlation Results
Using SPSS Student Version 22.0 software, a Pearson correlation coefficient was used to measure the relationship of bereavement, primary appraisals, secondary appraisals, coping skills, social support, and stigma among women whose military spouses had completed suicide. The correlation coefficient measures the strength and direction of the relationship among variables. When conducting a correlational analysis of two co-occurring variables, the researcher can indicate whether change in one is accompanied by systematic change in the other. Examination of intercorrelations among study variables indicated statistically significant correlations between bereavement and each of four independent variables: primary appraisal, secondary appraisal, coping skill, and stigma. The results for each correlation are presented separately and summarized below as well as in Table 1.
Control variable. There was a statistically significant relationship between time since death and bereavement for women whose military spouse had completed suicide, r(194) = .277, p < .01. The shorter the amount of time elapsed, the higher the bereavement scores.
Independent variables. Primary stress appraisal, r(193) = -.309, p < .01: There is a weak negative linear relationship between bereavement and primary stress appraisal. Secondary stress appraisal, r(193) = -.309, p < .01: There is a weak negative linear relationship between secondary stress appraisal and bereavement. Coping skills, r(193) = -.174, p = .015: There is a weak negative linear relationship between coping skills and bereavement. Social support, r(193) = -.039, p = .594: There is no linear relationship between perceived social support and bereavement. Stigma, r(193) = .252, p < .01: There is a weak positive linear relationship between perceived stigma and bereavement.
Table 1
Correlations for Independent, Dependent and Control Variables
CBI TSD PSAM SSAM MSPSS CSES
1. TSD .277*
2. PSAM -.309* -.167
3. SSAM -.309* -.151 .602*
4. MSPSS -.039 .032 .379* .172*
5. CSES -.174* -.167* .494* .473* .585*
6. STOSASS .252* .095 -.196* -.221* .022 -.253
Note: N = 194; CBI = Core Bereavement Items; TSD = Time Since Death (in months);
PSAM = Primary Stress Appraisal Measure; SSAM = Secondary Stress Appraisal Measure;
CSES = Coping Self-Efficacy Scale; MSPSS = Multidimensional Scale of Perceived Social Support; STOSASS = Stigma of Suicide and Suicide Survivor Scale.
*Significant at p < .05.
Multiple Regression
Following the correlational analysis, a multiple regression was utilized. This analysis was appropriate to describe the relationships between the independent or predictor and dependent or criterion variables in an objective manner (Lussier & Sonfield, 2004). The design was appropriate because the purpose of the study was to explain the relationships between variables.
Model 1 (TSD onto bereavement) yielded R = .277, R2 = .077, F(1, 125), p < .001. The portion of the variance explained was 7%. Model 2 (TSD and primary appraisal) yielded R = .431, R2 = .186, F(2, 124), p < .001. The portion of variance explained was 18.6%. Model 3 (TSD, primary appraisal and secondary appraisal) yielded R = .454, R2 = .206, F(3, 123), p < .001. The portion of variance explained was 20.6%. Model 4 (time since death, primary appraisal, secondary appraisal and coping skills) yielded R = .455, R2 = .207, F(4, 122), p < .001. The portion of variance explained was 20.7%. Model 5 (time since death, primary appraisal, secondary appraisal, coping skills and social support) yielded R = .471, R2 = .221, F(5, 121), p < .001. The portion of variance explained was 22.1%. Model 6 (time since death, primary appraisal, secondary appraisal, coping skills, social support, and stigma) yielded R = .482, R2 = .232, F(6, 120), p < .001. The portion of variance explained was 23.2% (see Table 2).
Table 2
Hierarchical Multiple Regression
| Model |
R |
R2 |
t |
p |
B |
β |
R2 Change |
| Model 1TSD |
.277
|
.077
|
61.600
3.228
|
.000
.002
|
.049
|
.277
|
0
|
| Model 2TSDPSAM |
.431
|
.186
|
19.482
2.696
-4.074
|
.000
.008
.000
|
.039
-.406
|
.222
-.335
|
.109
|
| Model 3TSDPSAMSSAM |
.454
|
.206
|
19.646
2.618
-1.947
-1.782
|
.000
.010
.054
.077
|
.038
-.254
-.192
|
.214
-.209
-.191
|
.02
|
| Model 4TSDPSAMSSAMCSES |
.455
|
.207
|
16.971
2.622
-1.952
-1.788
.266
|
.000
.010
.053
.076
.791
|
.038
-.262
-.199
.004
|
.216
-.216
-.198
.025
|
.001
|
| Model 5TSDPSAMSSAMCSESMSPSS |
.471
|
.221
|
12.989
2.307
-2.359
-1.111
-0.710
1.505
|
.000
.023
.020
.269
.479
.135
|
.034
-.335
-.132
-.012
.091
|
.192
-.276
-.132
-.083
.167
|
.015
|
| Model 6 TSDPSAMSSAMCSESMSPSSSTOSASS |
.482
|
.232
|
9.026
2.329
-2.187
-1.105
-0.320
1.107
1.280
|
.000
.022
.031
.271
.750
.271
.203
|
.034
-.312
-.131
-.006
.069
.086
|
.194
-.257
-.131
-.039
.128
.112
|
.010
|
Note: TSD = Time Since Death (in months); PSAM = Primary Stress Appraisal Measure; SSAM = Secondary Stress Appraisal Measure; CSES = Coping Self-Efficacy Scale; MSPSS = Multidimensional Scale of Perceived Social Support; STOSASS = Stigma of Suicide and Suicide Survivor Scale.
Qualitative Component
There is a growing interest in integrating qualitative data across quantitative studies to discover patterns and common threads within a specific topic or issue (Erwin, Brotherson, & Summers, 2011). The main aim of the qualitative questions within the survey is to gain insight into the participants’ world and capture their unique experiences (e.g., naturally occurring events and/or social or human problems) and their interpretations of these experiences (Jones, 1995; Sarantakos, 1993).
A total of 55 (28.4%) participants responded to the question, “What do you recall about how you responded to the death of your spouse at the time?” Of these, 24 stated recalling “sadness” as most frequent. Fifteen participants indicated disbelief, shock, feelings of helplessness or feelings of fear. Other participants’ responses included “trying not to think about what had happened,” crying, sobbing, physical symptoms, physical pain, collapsing, fainting, being unable to forget what happened, and being unable to recall or process the event. A total of 68 (35.1%) participants responded to the question, “What was the most painful part of the experience to you?” Of these, 50 reported physical and emotional numbness and only partial recollection of learning about the death (e.g., who told them, where they were when notified, immediate responses). These participants indicated that they could recall parts of the experience but struggled with identifying feelings or emotions directly following the event. Other responses included being hospitalized, contemplating suicide, refraining from eating, and feeling that their future had been lost. Although four reported contemplating suicide following the death of their spouse, no participants reported attempting suicide at any point. A total of 36 (18.6%) participants responded to the question, “How has this experience affected your view of yourself or your view of your world?” Of these, 15 participants indicated that they no longer feared death, while seven reported having a negative reaction to relationships. Eleven participants reported that they perceived stress as more threatening than before the suicide of their spouse and were unaware of the triggers that brought on stress during the bereavement process. Ten participants indicated that their view of love had changed since the loss of their spouse. Nine participants wrote about making an effort to enjoy life after the suicide of their spouse.
Discussion
This study investigated the relationships between bereavement and primary appraisal, secondary appraisal, coping skills, perceived social support and stigma among women whose military spouses had completed suicide. There are several study findings that deserve further exploration.
First, there was a statistically significant positive relationship between stigma and bereavement, suggesting that as female survivors perceive increased stigma regarding the suicide of their spouse, they present more symptoms of bereavement. Knieper (1999) suggested that bereavement following suicide is not the same as that following natural death. He reported that stigma and avoidance continue to be central issues for suicide survivors. Psychological projection of feelings of rejection and the actual social response to the survivor interact in a complicated manner. Worden (2009) also noted a difference between suicide bereavement and other forms of bereavement, suggesting that suicide is often associated with stigma and a sense of shame. Such shame can result in the complete isolation of the bereaved during the period immediately following the suicide event. Eaton and associates (2008) examined survivors’ barriers to seeking mental health treatment after the suicide of their partners and found that spouses were 70% less likely to seek treatment following a suicide, as compared to a natural death, and that stigma was a recurrent theme in the qualitative analysis. However, Eaton et al.’s study did not directly examine the impact of stigma on bereavement. It did show that stigma is an important variable that needs to be investigated further. The present study showed similar results to Eaton et al.’s (2008) research.
The qualitative comments recorded in the open-ended question section of the survey supported the study findings. For example, one participant responded, “I blamed myself for not doing more, not being there enough, or not being there when the death happened.” Another participant noted, “Suicide is one of the most difficult and painful ways to lose someone we love, because we are left with so many unanswerable questions.” One participant expressed the following:
[I felt] anger at family members for not assisting me with my husband and anger at physicians that treated my husband and were not able to see the warning signs or provide assistance in caring for them properly. I was then left with the scars after the death and had to explain to people what happened. I felt I got blamed and it was not my fault.
Several participants expressed “numbness and isolation.” Responding to stigma, people with mental health problems often internalize public attitudes and become embarrassed or ashamed. These feelings can lead them to conceal symptoms and fail to seek treatment (President’s New Freedom Commission on Mental Health, 2003). These survey responses assist in understanding the impact of stigma upon the military spouse survivors and imply that unanswered questions, as well as guilt, are important factors to explore in the grief process following a suicide.
Second, a statistically significant relationship between primary appraisal and bereavement was reported, suggesting that survivors who perceive the death of a spouse to be stressful are more likely to experience bereavement. This result is supported by the bereavement literature (Cvinar, 2005; Jordan, 2001; McIntosh, 1993). Lazarus (2005) argued that primary appraisal shows that it is not the situation, but the way a person interprets the situation, that affects the person’s experience. The way a person appraises a situation can impact the way the person reacts to it. Primary appraisal is an important step in processing the stress of bereavement, since grieving is such an individualized experience.
The qualitative comments recorded in the open-ended question portion of the survey supported the statistical relationship between primary appraisal and bereavement. For example, one participant indicated that her worldview had changed when she responded, “My world has become gray; I have made myself closed. I live in a rain cloud and now know that good people do bad things that change lives.” The participant had changed her worldview such that her world became a smaller, more restricted place. Another stated, “This death, this loss, makes small things seem insignificant. Material things are insignificant. Relationships with people are more important. I don’t have a fear of dying and in fact, feel like I will die at a young age.” This concept of primary appraisal is based on the idea that emotional processes are dependent on a person’s expectancies about the significance and outcome of a specific event. The same event within the same community (in this case, suicide within the military) can elicit responses of different quality, intensity and duration due to individuality in experiences and personality (Krohne, Pieper, Knoll, & Breimer, 2002). The different kinds of stress identified by the primary appraisal may be embedded in specific types of emotional reactions, thus illustrating the close conjunction of the fields of stress and emotion (Lazarus & Folkman, 1984).
Third, a statistically significant negative relationship was reported between secondary appraisal and bereavement, suggesting that survivors who make a negative appraisal of their ability to control the outcomes of their spouse’s death are more likely to experience bereavement. In the future, when examining outcomes of interventions that impact coping, beliefs about a person’s ability to perform specific behaviors related to coping would need to be highlighted. This concept is known as specific coping behaviors and is also pertinent to stress, coping theory and secondary appraisal (Chesney et al., 2006). Part of secondary appraisal is the judgment that an outcome is controllable through coping; another part addresses the question of whether or not the individual believes he or she can carry out the requisite coping strategy (Chesney et al., 2006; DiClemente, 1986; Hofstetter, Sallis, & Hovell, 1990).
The qualitative comments recorded in the open-ended section of the survey supported this finding. For example, one participant indicated her appraisal of the situation by stating, “Everyone must learn to face the misfortune, because life on the road will not be smooth.” Another stated that “time can dilute all and I must face life and accept my reality;” yet another wrote, “I want to work on longer range goals to give myself some structure and direction to my life and not focus on my loss. I am only interested in rebuilding my life.” However, other participants stated that it was harder to assess the loss and to move forward after the suicide. One participant stated the following:
I often find myself complaining to God about what seems senseless or unjust and unfair. I find myself bogged down in fear and even anger at myself or the person who died and “left” me. I do not accept what happen[ed] to me and my children.
Some participants reported not knowing what to do. An example of this feeling is the statement, “I perceive stress as threatening. I feel totally helpless.” Perceived self-efficacy, defined as a belief about one’s ability to perform a specific behavior, is a salient component of this theory. It highlights the importance of personal efficacy in determining the acquisition of knowledge on which skills are founded (Bandura, 1997; Chesney et al., 2006).
Fourth, a statistically significant negative relationship between coping skills and bereavement was reported, suggesting that survivors who believe they have a low ability to cope with their spouses’ death are more likely to experience bereavement. Although it is important for survivors to become familiar with the stress appraisal process, the way they assign meaning to their spouse’s death and their past experience with death also are important in their primary appraisal to the overall coping effort. One model of this process is the transactional model of coping (Lazarus & Folkman, 1984). This model of coping implies that a person’s appraisal of his or her interaction with a difficult event naturally evokes a coping response for dealing with the situation. Experiencing a suicide or living in a social environment that hinders, stigmatizes or isolates a person who has experienced a suicidal death may cause demands to exceed his or her resources for dealing with certain situations. Few studies have examined the natural coping efforts used by suicide survivors, or have identified specific problems and needs that survivors experience following the suicide of a significant other (McMenamy et al., 2008). Interventions with suicide survivors have limited effectiveness (Jordan & McMenamy, 2004). Provini et al. (2000) presented four categories of concerns for suicide survivors: concerns related to (a) family relationships, (b) psychiatric symptoms, (c) bereavement and (d) stress. Family-related problems were the most frequently mentioned type of concerns (Provini et al., 2000). Examples of family relationship concerns included inability to maintain parenting roles, inability to maintain family routines, existence of different coping styles within the family, and inability to provide appropriate emotional support to family members.
Qualitative comments recorded in the open-ended section of the survey supported this study finding. For example, one participant stated, “I often feel distracted, forgetful, irritable, disoriented, or confused. I try to remember how I got over a death in the past, sometimes it helps and sometimes it does not.” Another participant stated, “I know I need to start to form new relationships or attachments in my life but my mind [is] telling me ‘there must be some mistake,’ or ‘this can’t be true.’ ” Regarding bereavement, one participant wrote, “Grief is perhaps the most painful companion to death.” Addressing coping, one participant stated, “I must also adjust to working or returning to work after the death. I know things can’t go back to the way they were before, very difficult and painful to deal with and I better adjust to life.” These statements support the need to further explore the relationship between one’s ability to cope with the suicide of a spouse and one’s ability to experience and acknowledge feelings and move forward with everyday life activities (e.g., employment, childcare, financial obligations). Ability to cope impacts a person’s bereavement process; the ways and ability to cope vary with the individual. Stigma and amount of perceived social support have been correlated with ability to cope (Bandura, 1997). It is important to understand the individual impacts that stigma, social support, primary appraisal, secondary appraisal and coping have on bereavement. However, it is equally important to examine the relationships of these variables within the context of a model in order to establish future interventions for bereavement within the context of a suicide.
Fifth, results indicated that the model is statistically significant in predicting bereavement outcomes and provides considerable support for using the Lazarus model as a means of understanding the relationship between stress and bereavement when placed into the equation in a particular order: CBI = TSD + PSAM + SSAM + CSES + MSPSS + STOSASS.
This study suggests that the proposed model, using LCMS and assessment of stress, identifies the constructs associated with bereavement among women whose military spouses completed suicide. Future research could further explore the assessment of primary and secondary appraisal processes, coping, stigma, and social support enhancement programs and interventions to improve the bereavement process for military spouses. When survivors can identify and address their needs, the bereavement process following a suicide can begin (Christensen & Yaffe, 2012).
Limitations
First, the majority of the sample (54.1%) were non-Hispanic White, or Euro-American. Second, there is limited representation across military branches. Third, the study collected data from a self-administered electronic survey. Fourth, although the social support measure (i.e., MSPSS) has good reliability and measures social support as a general feeling of belonging to a social network that one can turn to for advice and assistance in times of need (Uchino, 2006), it does not delineate various types of social support. Finally, most of the sample consisted of women whose spouses had completed suicide while on active duty. Active duty members typically live on base and are well connected to the military community. When the military spouse dies, these supports are often no longer available, and the stigma of a suicide could strongly affect these women.
Recommendations for Future Studies
There are several practice implications from this study. The statistically significant correlations between bereavement and four other variables (primary appraisal, secondary appraisal, coping skills and stigma), as well as the significance of the LCMS construct of primary appraisal within Model 6, indicate that LCMS holds promise for understanding symptoms of bereavement in females following the suicide of a military spouse. Primary appraisal, the most significant variable within this study, could be highlighted within bereavement research on women whose military spouses have completed suicide. When conceptualizing the responses of these women, counselors and clinicians could use LCMS, examining the three components of primary appraisal (goal relevance, goal congruence and ego involvement) and exploring the ways these components present during the client’s bereavement process. The approach would focus on the role of maladaptive cognitions during times of stress (Sudak, 2009).
The reluctance of the military community to seek mental health support contributes to an inability to move through the bereavement process in a healthy way. Within the military community, it can be quite difficult to deal with the ambiguity of bereavement that is typically associated with emotional vulnerability (Lamorie, 2011). However, the current study suggests that four constructs—primary appraisal, secondary appraisal, coping and stigma—are significant when addressing the issues of bereavement in females who have lost a military spouse to suicide. Using LCMS to address cognitions, counselors might be able to assist a population whose members have been reluctant to seek mental health services in the past. Because the components of LCMS are correlated with bereavement, clinicians could use LCMS and cognitive stress research, which together seem to be a promising direction, when assisting women who have lost a military spouse to suicide.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Lindsey Mitchell, NCC, is the recipient of the 2015 Outstanding Dissertation Award for The Professional Counselor and a licensed counselor in both Texas and Washington, D.C. Correspondence may be addressed to Lindsey Mitchell at lmitch26@gwmail.gwu.edu.
