Review Abstract

REVIEW ABSTRACT

Group Therapeutic Storytelling Intervention as an Adjunct to Intensive Family Therapy
A SUICIDE INTERVENTION FOR ADOLESCENTS

Michael L Rimm, MD., FRANZCP, Kidz First Family and Community Mental Health (Campbell Lodge) South Auckland Health, Private Bag 93 311, Otahuhu, Auckland 6, New Zealand; R Phillips, MFT., S Fortune, M Psych Sc (Clinical Spec)., P Sender, MA, H. Clarkson, FRANZCP and the Team at Campbell Lodge Child, Youth & Family Service, South Auckland Health.

The Topic Campbell Lodge is the public sector community child and adolescent mental health services for South Auckland, New Zealand, serving an extremely diverse population of nearly 400,000 people. The demographics of this community are characterised by cultural diversity (including large population of indigenous Maori) and high levels of psychosocial stressors and economic disadvantage.

This community has high rates of youth suicide and multi-problem mental health needs. Therapeutic Storytelling Intervention (TSI), an innovative group therapy technique developed by Ron Philips, has been integrated with the delivery of intensive structural and systemic therapies. Outcome data suggest that TSI is a very effective with unparalleled compliance and survival rates in a population usually characterised by significant and rapid drop-out (King et al, 1997). In combination with intensive structural and systemic therapies helps reduce repetition of deliberate self-harm following a significant suicide attempt.

TSI rapidly engages resistant, hopeless and depressed adolescents, enabling family and wider systems therapy to proceed with the amelioration of risk factors. Clinical outcome measures and minimal repetition of deliberate self-harm over 1-year periods show promising results. Our team presented a workshop at the combined AACAP/Canadian ACAP in Chicago in 1999 and was well received. Follow-up data will also be presented. The Method of TSI Traditional group therapy for adolescents consists of encouraging them to reveal and discuss the problems they are facing in the highly influential peer group. Directly addressing their problems is not necessarily developmentally fitting and is too often met with high levels of resistance, and high drop out rates particularly for boys. Outcome measures for traditional group therapies for this age group are minimal and demonstrate poor compliance and variable outcomes.

The powerful influence of the adolescent peer group is not necessarily maximised in traditional group therapies (Misha et al, 1994). Used as an adjunct to intensive structural and systemic therapies, TSI is introduced to the adolescent and family during the initial crisis session either through the narration of a short segment of the story by the therapist or arrangements to commence a group. Groups are initiated on a regular basis with ongoing shortlist of group candidates maintained. The parameters are similar to many adolescent psychotherapeutic groups outlined in the literature.

A significant departure from many traditional approaches is the early introduction of paradox with in the form of 'there are only two rules (1) I wouldn't dream of talking when you are, and vice versa and (2) be honest with yourself and the process - 'if you don't want to say something just pass' rather than long periods of time generating and contracting rules for the group. TSI has become a method of communicating with adolescents who are hard to reach using many traditional methods, particularly those who are resistant to other treatment approaches and/or have poor peer skills. 'Gem of the First Water', written by Ron Phillips, serves as the basis for the story. 'Gem' of the First Water follows the adventures of a peer/hero, which mirror many common adolescent struggles.

The clinician/group leader tells a chapter of 'Gem' at each session in an oral, trance-like manner. The group is informed that they don't have to respond to any questions if they are not ready, may simply "pass" when asked questions, but are encouraged to be honest with themselves if and when they do respond. This method rapidly engages even resistant adolescents, often unknowingly. The story serves as a therapeutic vehicle and can provide a blueprint for change. There is no requirement for teenagers to reveal details of their own situation and no expectation of styles of participation dictated by the adults. TSI gives prominence to the message that everyone faces challenges, which minimises stigmatisation.

The collection of initial small-scale post-hoc evaluation data in 1997 stimulated much academic and clinical interest, which has been directed toward the establishment of a larger scale project. This project is entering the pilot study phase. Cognisant of this project, attendance and completion data have been evaluated for TSI groups between 1998 - 2001. During 1999/2000 more than 1/3 of clinic referrals were made following a suicide attempt or serious self-harm. As part of the development of a larger project the 346 clients who attended TSI at Campbell Lodge since 1997 have been monitored. Three out of every five attended more than 60% of sessions and are described as 'graduates'. (One third of non-graduates had legitimate reasons for dropping out of the group such as moving out of the area or having significant transport difficulties). On average, TSI groups run for 16 weekly sessions. Average attendance among clients who commenced TSI was 67% across the period. Among graduates average attendance rates were 89%, 86%, 87%, 87% and 83% respectively for 1997, 1998, 1999, 2000 and 2001. Attendance appears to be higher than in many other programmes for depressed/suicidal adolescents with other advantages being the successful treatment of a heterogeneous group of adolescents with regard to psychiatric diagnosis, gender, ethnic and socio-economic backgrounds.

As part of quality improvement in 1999 we began creating a clinical profile of clients entering TSI using internationally accepted measures of depression, behavioural problems, family functioning, suicide ideation and self-harm behaviours. These measures were repeated when clients completed TSI. These clients represent a high-risk population for suicide behaviour given significant rates of psychiatric comorbidity, substance use and exposure to abuse and are not excluded from this evaluation data. Data indicate a significant reduction of ineffectiveness, anhedonia, negative self-esteem, depression and parent rated improvements in internalising behaviours, attention problems and overall behaviour. In addition clients report a perceived improvement in how they relate to their families across domains of problem solving, communication, role clarity and affective involvement. Further, crisis re-presentations appear to be significantly lower in comparison with outcome studies of similar populations.

Goals of Workshop

The goals of this workshop are to describe the nature and process of the program as developed in South Auckland, New Zealand. South Auckland has a very high and unacceptable rate of youth suicide among a multicultural, low socio-economic population, which has been under-resourced in terms of mental health services. Participants will be introduced to some of the challenges facing such a high-risk population, the development and techniques of the program, and some preliminary outcomes. The power of utilising TSI as a method to engage depressed/suicidal adolescents in the treatment process will be demonstrated by Ron Phillips. Participants will be provided with some handouts and will have access to further materials. The workshop will be interactive and will provide the opportunity to participate in TSI.

References: King, C.A, Hovey, J.E., Brand, E., Wilson, R. & Ghaziuddin, N. (1997). Suicidal adolescents after hospitalisation: parent and family impacts on treatment follow-through. Journal of the American Academy of Child and Adolescent Psychiatry, 36. 85 - 93. Mishna, F., Kaiman, J., Little, S. & Tarshis, E. (1994). Group therapy with adolescents who have learning disabilities and social/emotional problems. Journal of Child and Adolescent Group Therapy, 4. (2). 117 - 131. Leader, E. (1991). Why adolescent group therapy? Journal of Child and Adolescent Group Therapy, 1. (2). 81 - 93