Out of Options: A Cognitive Model of Adolescent Suicide and Risk-Taking

Kate Sofronoff is currently a Lecturer in Clinical Psychology and Len Dalgliesh is a Senior Lecturer in Judgment and Decision Making in the School of Psychology, University of Queensland, Brisbane, Australia. Robert Kosky is Emeritus Professor of Child Psychiatry at the University of Adelaide, Australia. These three authors have combined their academic and clinical experience in an attempt to tackle an area of adolescent behavior that presents a serious and important challenge for parents, teachers, and professionals the world over.

These authors have a long-standing interest in adolescent suicidal behavior. The first four chapters of the book describe the epidemiology of adolescent suicide, risk, and emotional and cognitive predisposing factors in adolescent suicide. The authors then look at risk-taking and the common variables between risk-taking adolescents and suicidal adolescents. Finally, the authors focus on one aspect of suicide prevention, the role of cognitive mediators and the suicidal thinking/decision of adolescents.

It is their clinical impression that adolescents who attempt suicide are in many ways similar to adolescents who take serious risks and end up in the juvenile justice system. They postulate that both of these groups, the risk-takers and suicidal adolescents, have long-standing serious and similar cognitive deficiencies. They describe two programs to improve problem solving in symptomatic adults—the Problem Solving for Life Program and the I Can Problem Solving Program. Although they do not indicate they are specific to Australia, I am unfamiliar with the use of these programs in the United States.

The Problem Solving for Life Program requires that high school students work in groups, fitting together puzzle pieces that have positive or negative phrases written on them. Each group then decides where the puzzle fits on a poster. On a positive poster there is a movement from the problem to thinking (“It’s a challenge, at least try”), to feeling (“good feelings, excitement”), to doing (“relaxing, thinking, growing, positive alternatives”), leading ultimately to an effective solution, i.e., thinking, feeling, and doing. In a similar way a negative poster has unhelpful thoughts written on it, which lead to negative feelings and then poor solutions. The authors admit that obviously not all life problems have solutions. All coping does not lead to a positive response. This program also offers suggestions as to where the adolescent might go for support when problems seem unmanageable.

The other program, the I Can Problem Solving Program, is an interpersonal cognitive program for children and adolescents. It was designed to teach children to think in ways that will help them to resolve interpersonal problems successfully.

These two programs seem like very simplistic solutions to very complicated problems. They do not take into account many of the predisposing factors to depression and suicide, such as life events, the loss or rejection by a friend/boyfriend/girlfriend, family dysfunction, problematic family interactions, genetic predisposition, experience of abuse as a child, family history of psychiatric illness, and personal history of psychiatric illness, to name just a few predisposing factors.

I believe that most adolescents would be turned off by these simplistic exercises. They might pretend to follow a program but really not do so, and certainly they would not be challenged. These programs might in fact be counterproductive rather than efficacious or helpful.

This book (which is easy to put down) does not really propose any new theory or any new approaches that might deal with old, existing theories, such as the links between early environmental risk factors, psychopathology, and problematic cognitive skills. The connection between risk-taking behavior and suicidal behavior is not a new discovery to anyone who has worked in a therapeutic role with an adolescent or anyone who has worked in a clinical setting with a disturbed adolescent. It has been clear for a long time that problem-solving and decision-making skills are important. Many seriously disturbed adolescents would mock, deride, and not participate in programs such as the Problem Solving for Life Program.

A program designed to enhance decision-making and problem-solving skills has to be embedded in something attractive and enticing to ensure adolescent participation. These authors punted the task of designing such a program to someone else. Designing a program is a challenging and daunting task, and I doubt anyone will accept their challenge. The needs of adolescents with conduct disorders and suicidal adolescents are so great and multifactorial that single programmatic development designed to enhance specific decision-making and cognitive skills likely will be ignored as more pressing needs of disturbed adolescents are attended to.

This is not a book that I would recommend to medical students, residents, or fellows. Nor would I recommend it to other colleagues in the mental health profession. The central point of this book, i.e., that risk-taking and suicidal behavior are linked, is well-known and does not need to be reemphasized to the mental health practitioner.