According to CDC (2016), suicide among children and the youth is a global health crisis. As per CDC (2016), in every eight children aged 6 to 12, one usually has suicidal thoughts. It refers to the intentional imposing of danger to oneself until death. Suicidal attempts are more common than the act itself since it is a harmful behavior to die. (Carr, 2020). According to CDC (2016), suicide is the common leading root of death among persons aged 10-24 years in America. The majority of children that commit suicide usually have underlying mental health issues.
There are many risk factors of suicide in children, including physical abuse, family history of suicidal ideations, poor coping skills, impulsivity, losses, lack of material support, and availability of means of committing suicide. Studies have shown that family negligence and poor social support are the top risk features (Asarnow & Mehlum, 2019). Evidence has shown that children who commit suicide often experience issues with family or friends’ relationships (Carr, 2020). Such children are likely to undergo depression, dysthymia, and attention deficit hyperactivity disorder.
There are subtle warning signs of suicide such as withdrawal from friends and family, psychosomatic problems, insomnia, changes in eating patterns. A drop in performance at school can be a warning sign (Erdem & Safi, 2018). Additionally, preoccupation with death, by making statements that suggest suicidal ideations and feelings of hopelessness are critical, threatening signs which should be taken seriously, and parents should ask questions regarding such a change of baseline behavior. Regardless of the answers to the queries, the parents should seek help from a mental health practitioner.
Moreover, the suicide of children affects the family members’ psychological health and paralyzes the functions of the household. The grieving relatives will then go through stigma, psychological depression, feelings of guilt, and anger, though nearly half of the suicide and its attempts can be prevented (Korczak et al., 2020). Most of the children that kill themselves pose most of the warnings as mentioned earlier. Parents, teachers, friends, and siblings are the best people to pick up those signs and intervene before it is too late. When everyone in the family and the community are committed to prioritizing suicide prevention and are empowered to take the proper measures, these cases can be prevented.
Since most of these circumstances are due to impaired family processes, negligence, and social isolation, family therapy is critical in preventing this occurrence. Family therapy is a form of psychotherapy that involves everyone in the household and the identified patient. It focuses on the family interactions, processes, and general functions of the people concerned. The therapy works through the members’ communication processes to identify the clinical problems (Asarnow et al., 2017). Family is handled as a unit because family member symptoms are as rare as distress and failure in the general functioning. This treatment focuses on both psychosocial and behavioral interventions. The paper will focus on the effectiveness of family in preventing suicide in children.
Bowen Family System Theorem
The above model was established by a psychiatrist and scientist called Dr. Murray Bowen. He described self-differentiation, which represents maturity levels in relationships (Olson et al., 2019). it describes the ability to think on an individual basis while staying connected to others. It designates the capacity of individuals to strike a balance between emotions and intelligence. It also represents the balance between the need to remain attached to others and to disconnect from oneself. Bowen proposed that the best way to have self-growth is through authentic family relationships. The theory suggests that avoiding family because they are challenging is a bad habit and adds to managing relationship upsets (Carr, 2020). The self-differentiation theory suggests that an individual can think better without emotional breakdown and stay connected to others. People get close to self-differentiation when they demonstrate a moderate range of emotional maturity.
Bowen’s concept gives precise critical information regarding how persons handle stressful situations in life. The excellent psychiatrist theory borrows Charles Darwin’s idea on evolution, which brings in the perception of organism modification through natural selection. Darwinian concept acts as a reference to Bowen’s family systems theory (Olson et al., 2019). Most of the challenges in human life are due to unresolved issues in their minds. After conducting intensive studies of different patterns of solving problems and anxiety in families, Bowen concluded that such marks are the same species that the surrounding has threatened. Responses taken after a threat to the family processes are the major causes of weak connections in most families. The decision to retreat and avoid the danger poses more challenges to unity. The concept focuses on relationship challenges that affect humans. (Olson et al., 2019). It does not focus on an individual difficulty but rather the patterns of systems that pose relationship challenges.
Thus, this is a call to human beings to observe the world from each family member’s lens and not from oneself, instead of witnessing situations from the viewpoint of victims and villains in the relationship. Seeing the system patterns goes beyond blame games but rather considers the forces driving people in different paths. In an attempt to elaborate the concepts of family systems, the theorist gave eight clinical ideas. They include self-differentiation, distorted families’ emotional systems, cutting off emotional baggage, multigenerational emotional unit, family triangles, family projection procedures, societal involvement in emotions, and sibling role process.
The Relation Between Bowen’s Theory and Family Therapy
Bowen’s theory is not a unique model that focuses explicitly on how to structure the sessions. Family therapy goals in preventing suicide are to achieve greater self-differentiation in the suicidal child with less fault-finding, reactivity, and greater emotional maturity. In the prevention of suicide, the theory views the therapy in three dimensions (Thompson et al., 2019). In the first stage, the therapist focuses on the client’s symptoms to alleviate anxiety and understand them as part of life. In the prevention of suicide, this stage can be applied by focusing on the warning sign of suicides and the reasons for such thought’s ideations (Walsh et al., 2018). The second stage is on the child’s adult members to achieve self-differentiation and resist the family’s togetherness force. The therapy focuses on the mature associates of the household to balance the need to have self-time and attach themselves to the family (Carr, 2020). This will improve the family functioning and process, which are the first procedure in children’s suicide prevention.
The Bowen theory’s first sessions start with the family evaluation and history taking to learn the processes. This offers all members information on the presenting issue in a structured setting (Cha et al., 2017). The problem can use a multigenerational genogram to trace the suicidal issues from the nuclear to the extended family, especially once there is a history of the case among relatives. The therapist learns the emotional patterns of the household anxiety and issues with closeness and relationships. They also know the family’s adaptivity to stressful situations and the triangles that get activated in traumatic situations.
The therapist can use this theory in suicide prevention in ensuring connection with the family without being emotionally reactive (Jiménez et al., 2019). For effective suicide prevention therapy, the therapist must maintain a differentiated stance. They should be calm and interested in the investigations and issues behind the warning signs and the change of children’s baseline behavior. This will help the family to understand that it is an emotional system. Family therapy is not based on healing or help, whereby the members wait for the cure of their child. It ensures participation of the family for the change of situation.
In the interaction with the suicidal child, the therapist should direct the therapeutic conversation to alleviate the child’s anxiety and open up. In theory, the children are encouraged to talk to these experts so that the other household members could listen for the first time without becoming emotional. Bowen would focus on interrogating one partner in the attendance of the other. Like Bowen, family therapists should avoid asking sensitive questions, reducing the likelihood of self-differentiation (Cha et al., 2017). This activity is known as externalizing the thinking of one family member in the presence of the other.
In as much as Bowen tried to minimize the tendency of involving children in the last stage of the theory, this treatment is well applicable in children’s suicide prevention (Olson et al., 2019). The family therapist should include the child in the first session of the management to learn the client’s problems and the family as a unit. He should then apply detangling maneuver to exclude the youngsters from the sessions and involve the adults. When the child’s parent understands the problem, they can help take action to prevent suicide. In general, the change of a suicidal child is viewing in three steps; first, the child takes the position to change; second, the family members react; and lastly, the new stance is maintained.
Literature Review on the Effectiveness of Family Therapy
Psychosocial interventions have been shown to be better in comparison with other methods of preventing suicide among children. Studies have revealed that family therapy is one of the critical types of psychotherapy in preventing children’s cases (Asarnow & Mehlum, 2019). Its effectiveness is compared to the usual care and medications. Some of these suicidal ideations are usually due to impaired family processes, as proposed by Asarnow et al. (2017). The meta-analysis of about 17 interventions regarding the suicide of children and adolescents showed that those who received family-focused interventions were likely to have suicidal ideations and attempts post-test than the controls. Studies have shown that family therapy-focused treatment for the children is effective for short-term care, but in the long term may increase the chances of suicidal events but decrease the ideations’ circumstances. This process demonstrates a promising intervention in the general prevention of suicide.
Intense family interventions have shown a marked decrease in self-harm and suicidal reductions. This is in line with Carr (2020) that family therapy mobilizes the existing strengths and identifies the gaps present in the relationships that could cause suicidal attempts and ideations. It is a logical intervention for self-harm in children since there is enough evidence of psychotherapy to prevent repeated episodes of self-harm. This concurs with a systematic review done by Carr (2020) that suggests that family therapy identifies broken relationships and emotional instability within it as a unit. It also ensures that each member, including the children, learns the self-differentiation tactic. The treatment also decreases the feelings of worthlessness more often experienced in children who experience suicide ideations. It also reduced depression which is the most common cause of suicide. Children treated with family therapy had faster reductions in the symptoms than when they were given usual care and medications.
Attachment-Based Family Therapy in Preventing Suicide (ABFT)
The usage of attachment-based treatment reduced the symptoms by four times by the end of the treatment, usually three months. This was in comparison with patients who obtained individual cognitive behavior therapy and those treated in the community. Teens treated with ABFT demonstrated a faster reduction of depression symptoms. Most treatment work with adolescents and children alone without realizing the significant influence parents have on their children. Furthermore, family conflicts, ineffective relationships are the most common causes of suicide, and they can be prevented by family love, communication, and trust.
Body of evidence has shown that the therapy strengthens family relationships, resolves conflicts, and rekindles love that reduces the feelings of guilt and depression that can result in self-harm. This is backed by Cha et al. (2017), who termed the family members as curative medicine since they are critical in keeping the communication lines open in children with suicidal behavior. Carr (2020) states that although Family-focused therapy alone cannot prevent self-harm recurrence, it can be used in reducing the symptoms. Thus, in combination with other measures, it can minimize suicide cases in the world.
He further suggested that the various types of families share the same approaches and have multiple standard features. They start with the children and the family’s engagement as proposed by Bowen and then proceed to the adults and finally devising suicide prevention measures and the action plans (Carr, 2020). The plans consist of individual therapy for the patient and then systemic therapy to restore the family processes. Carr (2020) concludes with the body evidence that most treatments such as ABFT, multisystem therapy, dialect, and behavior therapy all use the same approaches and have a significant role in reducing suicide cases.
Multisystem therapy is used in adolescents with severe mental illnesses and suicidal depression. Studies have shown its effectiveness in children’s conduct disorders and the management of suicidal ideations (Erdem & Safi, 2018). It generally involves suicide assessment of a child followed by intensive family therapy. It is coupled with teaching adolescents the skills to control their emotions and mood and lead them to the need for social support and effective conflict resolutions to improve their mental health.
The treatment includes regular home-based family and individual therapy with another session in the school or community, which grants the treatment its name. Researchers have concluded that the family’s inclusion in this type of treatment is the reason for the marked improvement of the children who go through it. Cha et al. (2017) investigated the process’s effectiveness in suicidal children using 156 randomized clinical trials. Compared to hospitalizations and medication, multisystem family therapy was more efficacious in reducing the suicide attempt rates in one-year follow-up.
Lastly, family and systemic interventions for children who demonstrate self-harm and suicidal attempt behavior should involve a prompt initial assessment of the young individuals in the relatives’ presence as proposed by Bowen (Jiménez et al., 2019). It should be followed by a family assessment of its functions and procedures. Systemic therapy whereby the household resources are assessed, and then options for brief hospitalizations should be explored (Korczak et al., 2020). Hence, the proposed interventions should include all the family members and the client.
Discussion and Implications
Since difficulties significantly affect any family members, family-focused psychotherapy is among the most vital interventions. This treatment has proven to prevent suicidal attempts and events among children effectively (Jiménez et al., 2019). However, most of the studies were specific on its excellent short-term efficacy compared to the long-term effectiveness. This shows the necessity to couple it with other treatments, such as medications and other management, to achieve its long-term effects. In most cases, the risk factors of self-harm are failed family processes and multigenerational issues. The therapy effectively restores functions and relationships of the family (Carr, 2020). The above approach can be used in many psychiatry symptoms in the adolescent, such as depression, conduct disorders, and all other factors such as suicide attempts.
Furthermore, the self-harm and suicide of children are complex and have multiple facets. Therefore, applying the systems theory in addressing the role of a therapist and the family members’ involvement is crucial (Cha et al., 2017). The expert should be tactical in assessing and interacting with the family members to ensure a practical approach and prevent emotional attachment. The therapist should be aware of the remedy’s short-term effects and its reduced effectiveness on a long-term basis. This should inform the incorporation of other methods into the studies. The treatment also resolves adolescent and parent conflicts and improves their relationships.
Furthermore, the therapists should be aware of the therapy’s weaknesses, such as the emotional effect of some of the confidential and secret information that the child may disclose in data collection to the family members. This can cause guilt and shock, especially if the family members were not aware of it. The literature highlighted in the review does not investigate the effects of this on the family’s patterns.
Hence, the Bowen systems theory approach in family therapy, which was majored in this paper, has a limited body of evidence regarding its effectiveness on suicide in children. Furthermore, the theory uses a detriangulation maneuver to exclude children in the therapy’s advanced stages (Jiménez et al., 2019). Family therapy also encourages neutrality, which can be interpreted as tacit approval to harmful behavior. Therefore, a therapist should be careful when using the theory in preventing suicide ideations.
Due to the increasing number of suicide cases, more studies need to be done on various types of family therapy and other psychotherapies in preventing suicide. Bowen systems theory is one of the most utilized models in the care of suicidal patients, and a further increase in its evidence of use will improve its efficacy. The effectiveness of family therapy in suicide prevention has been researched and seen to lower the risk of suicide by four times compared to medications and other psychosocial interventions. The duration of the effectiveness is a question that needs further studies and the rate of relapses of the suicide ideations and attempts. This information helps the therapists, parents, and any other person who needs empowerment in preventing suicide against children.
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