Timo Purjo's presentation, Vienna 2016

SUICIDE PREVENTION IN ADOLESCENCE:
A MEANING-CENTERED APPROACH
The Future of Logotherapy
3rd International Viktor Frankl Congress
Vienna, September 22-25, 2016
Timo Purjo, PhD

TIMO PURJO
Biographical Sketch
Degrees earned:
Doctor of Philosophy, University of Tampere, Finland
Diplomate in Logotherapy, Viktor Frankl Institute of Logotherapy, Abilene, Tx,
USA
Other:
Accredited member of the International Association of Logotherapy and
Existential Analysis
Chairman of Viktor Frankl Institute Finland
1996-2015: Vice-Chairman and Director (R&D) of Non Fighting Generation (NGO),
Finland
Correspondence and contact
Postal address: Timo Purjo, Heinätie 8, 12700 Loppi, Finland.
E-Mail address: timo.purjo@pp.inet.fi.
Telephone (mobile, both daytime and evening): +358-400-607792. 9/24/2016© Timo Purjo
2

OUTLINE
1. Introduction
2. Objectives and goals
3. Methods
4. Research project: Findings & conclusions
5. Development project: Outputs
6. Development project: Results
7. References
8. Comments and questions
9/24/2016© Timo Purjo
3

1. INTRODUCTION
• Focus of the presentation
• the phenomenon of human suffering and the ultimate
outcome of it, suicide, and how it can be prevented among
adolescents by a meaning-centered approach
• Presentation based on
• research and practical experiences in Finnish youth education
organization Non Fighting Generation
• Non-governmental organization specialized in helping violently acting
(against others and/or self) young persons; 1996-
4

1. INTRODUCTION
 3-years research project (2011-2013) on the subject of suicidal
and self-destructive behaviors of young people (adolescence
acting violently against themselves), in co-operation with National
Institute for Health and Welfare (THL)
 Subsequently 3-years development project (2013-2015) - also
with THL - in which all in the previous project gathered theoretical
knowledge was put into practice
 The purpose was specifically on providing for health professionals new
methods that give them greater visibility of the risks of suicidality than
with currently dominant methods, and enable them to make interventions
with the intention to prevent self-destructive behavior as early as possible
5

1. INTRODUCTION
• Target group: 13-25-years old adolescents and young adults who
suffer from experiences of lovelessness, meaninglessness, and
despair, and who also have symptoms of some kind of self-
destructive or suicidal tendencies
6

2. OBJECTIVES
 Research project
 To discuss the phenomenon, i.e. the self-destructive and suicidal
behaviors of young persons
 To introduce some of the basic principles and viewpoints of our
existential and meaning-centered approach in preventing young person’s
suicides
 To examine research on risk factors as well as protective factors for
suicidal behavior in adolescence
 To analyze critically the currently dominant view of self-destructive
behavior and its prevention and treatment
7

2. PURPOSE AND GOALS
 Development project
 Create methods that help professionals
1. to anticipate and prevent youth suicides and all kinds of self-destructive
behavior as early as possible (at least before a first suicide attempt);
2. to encourage self-destructive adolescents to find, despite their
disturbances and difficult life situations, some valuable point of
references to themselves, to their lives, and to the world around them;
3. to promote meaningful experience in their lives
8

3. METHODS
 Research project
 Integrative literature review
 Reviewing research literature, discussing it and making conclusions
 Key literature: 32 articles, 5 books
 Development project
 Development
 Developing existential and meaning-centered methods for youth suicide and self-
destructive behavior
a) risk assessment,
b) short-term intervention, and
c) longer-term individual counseling and support based on a Logotherapeutic
approach
for the use of health workers and psychiatric nurses working in schools and public
health centers
9

3. METHODS
 …Development project
 Training pilots
 23 sessions
 Piloting
• 58 professionals from 9 organizations in different-sized cities in Southern (Helsinki /
metropole region), Middle and Eastern Finland
• Adolescents participated during developing and as target persons
• Separate methods piloted 863 different times with 621 adolescents
 Reporting
 Theory book
 Method manual (open access)
 Spreading
 6 presentation and training seminars
 105 professionals
 Information through piloting organizations and by email up to Northern Finland
10

4. RESEARCH PROJECT: FINDINGS &
CONCLUSIONS
• See www.slideshare.net/TimoPurjo: Self-Destructive
Behavior and Suicide Prevention in Adolescence,
Presentation at 19th World Congress on Logotherapy,
June 19-23, 2013, Dallas, Texas, USA
11

4. Findings
Suicidal and self-destructive behaviors
• Occasional thoughts of death or suicidal ideation are common
and normal. In adolescence, the suicidal thoughts are often
related to current difficulties. Milder, transient suicidal ideation
without suicidal plans does not usually involve a conscious
desire to die; however, behind these thoughts there may be an
unvoiced wish that a difficult situation or state of affairs would
get better. Instead, recurrent or persistent suicidal thoughts or
plans have more a serious character — especially if the ideas are
related to a suicide plan or a strong desire to die.
© Timo Purjo

4. Findings
• Worldwide life-scale prevalence of suicidal ideation is about 9%, and
suicide attempts about 2.7%. Age is negatively associated with
suicidal behavior; that is, young people and young adults are
strongly represented in suicidal behavior. Evans et al. (2011)
investigation indicates that up to 30% of young people have thought
of committing suicide and about 10% have attempted suicide.
• Some studies suggest that up to 17% of the people harm
themselves during the life course (Whitlock et al., 2006).
Furthermore, non-suicidal self-injury increases the risk of suicide
(Hooley, 2008.) Non-suicidal self-harm is particularly common
among young people. In Western countries, 5-9% of young people
harm themselves each every year (Skegg, 2005).
© Timo Purjo

4. Findings
• In one Finnish study (Laukkanen et al., 2008), up to 11.5% of
young people aged 13-18 had harmed themselves. In particular,
young women appear to be at risk in this respect: Female’s self-
harm figures are up to eight times higher than those of males,
however, in adulthood, the gap narrows considerably between
the genders (see Hooley, 2008).
© Timo Purjo

4. Findings
Research on risk and protective factors for
suicide and suicidal behavior in adolescence
• Research on risk factors for adolescent suicide provides the
basis for suicide prevention. The vast majority of research on
suicide risk and traditional suicide risk profiles has focused on
negative factors that predict suicide attempt risk and increase
the chances of an individual engaging in deliberate self-harm.
• Current research with adolescence has found that (1) previous
suicide attempt, (2) presence of a mental disorder (especially
mood disorders), and (3) presence of substance/alcohol misuse
constitute the most prominent risk factors for completed suicide.
© Timo Purjo

4. Findings
Research on risk and protective factors for
suicide and suicidal behavior in adolescence
• Recent research evidence in China, based on psychological
autopsy studies of suicide decedents, have indicated
substantially lower rates of mental disorders in Chinese suicide
victims compared with those in respective Western studies
(Phillips, 2010; see also Pelkonen et al., 2011).
• As Pelkonen, Karlsson and Marttunen (2011) have pointed out,
this may have important implications for both the theoretical
modeling of suicidal behavior and the development of suicide
prevention strategies — especially given the fact that China
accounts for as much as 1/3 of global suicides.
© Timo Purjo

4. Findings
Critique of current theoretical model of
suicide prevention
• Marsha M. Linehan (2008) has stated, ‘the central theory of suicide
and suicide prevention that has shaped suicide prevention research
to date contends that suicide is a symptom of a mental disease and
prevention of suicide requires treatment of the underlying disease’.
• Yet, none of numerous published randomized clinical trials, which
have investigated interventions for depression, substance abuse, or
schizophrenia – disorders commonly associated with suicidal
behaviors – have not shown that reducing the symptoms of mental
disorders would also reduce the incidence of suicide attempts or
suicide. Moreover, treatments targeting suicidal behavior alone have
been much more effective than those targeting presumed underlying
mental disorders.
© Timo Purjo

4. Findings
suicide prevention
• Utilizing a complementary approach, suicidal ideation, suicide
attempts, and completed suicides are not reduced to the symptoms
of mental health problems (e.g., depression). Instead, Linehan
(2008) contends that suicidal behaviors should be conceptualized as
‘dysfunctional and disordered individual and social behavior’.
• From this point of view, self-destructive and suicidal behaviors could
be conceptualized as inability to cope with life demands as a result
of lack of sufficient individual and social resources. This different
approach to suicide risk assessment, which has been studied during
the last three decades, has been conceived mainly as a result of the
development of the Reasons for Living Inventory (RFL; see e.g.,
Linehan et al., 1983).
© Timo Purjo

4. Findings
suicide prevention
• While most studies have focus primarily on negative risk factors, RFL has
been developed to investigate the factors that protect and prevent
individuals from committing suicide, and inspire them to live in the face of
hardship and adversity. Linehan and colleagues (1983; 2007; 2008)
emphasize that suicidal compared to non-suicidal individuals lack positive
beliefs and expectances in life and have fewer concerns regarding the
consequences of suicide for their social environment.
• Linehan and colleagues have identified six reasons for living. Individuals who
possess these reasons for living (e.g., “I believe I can find other solution to
my problem” and “I have courage to face life”) reflected in the inventory are
hypothesized to be less likely to attempt suicide than those who do not. This
hypothesis could play an important role in understanding suicide risk.
© Timo Purjo

4. Findings
suicide prevention
• Having more reasons for living differentiates between those who do not
have a history of suicide attempt and those who do — despite comparable
severity of mental health problems and recent adverse life events.
• Emphasis on reasons for living is also consistent with an existential and
meaning-centered approach to understanding suicide in which the
emphasis is placed on human strengths and well-being rather than on
emotional vulnerability and symptoms of mental health problems. From
an existential and meaning-centered perspective, it is particularly
important to investigate these positive factors — the strengths and
resiliency — that help to protect and prevent person from suicidal
behavior in spite of mental health problems or stressful circumstances
that can lead to despair.
© Timo Purjo

• What is ‘suffering’, after all?
• From an existential point of view, different kind of mental health
problems, substance misuse or abuse, extremely stressful life
events, or self-destructive behaviors, can all be understood as
the manifestations of the larger human phenomena — frustration
in the search for meaning (‘existential frustration’), feeling of
inner emptiness (‘existential vacuum’), and meaninglessness.
Suffering without meaning leads to despair, as Frankl has stated,
and despair caused by these kinds of devastating destinies or
functional disturbances, may lead to such a crisis where a young
person can’t find a way out but by suicide.
© Timo Purjo
4. Findings
An existential and meaning-centered
approach to young person’s suicidality

• Viktor Frankl’s book, Man's Search for Meaning, ends with a Chapter
on Tragic Optimism. By the use of this term Frankl expresses the
view that everything can be taken away from a human being, except
the last area of freedom — the freedom to choose one's attitude
towards unavoidable circumstances. Thus, our existential and
meaning-centered approach does not concentrate so much on the
background of the suicidal behavior (e.g., above-mentions risk
factors) but instead to an individual’s distinctive possibilities as a
person.
• What does this mean from a practical point of view in treating a
young person who has some suicidal tendencies?
© Timo Purjo
4. Findings

• One of the central issues in working with suicidal adolescents is their self-
centered focusing on deficits, disturbances, and problems in their life and
in themselves, which diminishes any positive aspects and hinders their
ability to create some distance between themselves and their problems.
• However, even a high risk person is always more than their disturbances,
problems, incapacities, or self-destructive behavior. That is one of the
reasons why suicidal adolescents should not be approached through their
deficits or derangement. Furthermore, when a young persons gets caught
in this kind of a vicious circle of rumination and identifying themselves
with these negative attributions and adverse symptoms, it can make their
situation even worse (Morrison & O’Connor, 2008; Miranda et al., 2013).
• Frankl calls this state hyper-reflection.
© Timo Purjo
4. Findings

• Hyper-reflection can be counteracted with de-reflection, which helps one
to redirect their attention from problems to unique meaning potentials
life offers from moment to moment. This technique is based on the self-
transcendence, the human capacity to become directed to something, or
someone, other than itself — be it a meaning to fulfill or another human
being to encounter lovingly. Furthermore, although some people have
the intuitive capacity to resort to their inner resources and power of will
challenging life circumstances; in preventing youth suicides, it is
extremely important to help adolescents to become aware of and
develop their defiant power of the human spirit, so they can overcome
their biological, psychological, or sociological limitations, and resist their
disfavorable abilities, circumstances and experiences—to the extent that
they can permanently avoid getting assailed by such destructive forces.
© Timo Purjo
4. Findings

• An aid and support should not either stop at the point when the acute
crisis has passed; on the contrary, there is so much more that can be
accomplished. Crisis is always both a threat (to freedom) and a
possibility (for growth). Once the threat has passed, one can begin to
take advantage of all the opportunities the crisis has provided. In
logotherapeutic healing the target is not only to restore one’s pre-crisis
operational capacity, but to find ways to enjoy a more meaningful and
purposeful life for the future (Long, 1997). Thus, the fundamental
purpose of intervention is help those in distress become people who
are able to intuitively activate their defiant power of the human spirit
in the face of crisis and maintain the sense of meaning and purpose in
spite of adverse circumstances
© Timo Purjo
4. Findings

© Timo Purjo
4. Findings
Stage 7
“Transcending the Trauma”
Stage 1
Current Level of Stage 6
Functioning Return to Previous
Stage 2 Baseline Level of Level of Functioning
Onset of Crisis Functioning
-------------------------------------------------------------------------------------------------------------------------
Stage 3
Rapid Descent Stage 5
into Despair Progressive Improvement
during Clinical Intervention
Stage 4
“Bottoming Out”
Long, Jerry L. Jr. (1997) Logotherapeutic
TranscendentalCrisis Intervention,
The International Forum for Logotherapy,
20 (2), 104-112.

4. Conclusions
• Existential issues, like meaninglessness, are a central part of suicidality.
Anton Nindl (2004) has stated: the ‘question of meaning is the one we
have to confront again and again while working with suicidal people’.
Meaning-centered approach, which emphasizes the spiritual side of
human being and the significance of meaning in life, brings a fresh
perspective to mental health treatment and etiological examinations.
• When adolescents indicate that they find that suicide is the only
possible route out of suffering, focus should be on keeping them alive
by providing hope and meaningful reasons for living. However, this
should not be based on false promises or empty hopes but on a
dialogue which reveals to a young person that there is some
meaningfulness in world, positive reasons for living, and something
valuable in oneself.
© Timo Purjo

4. Conclusions
• In suicide prevention, it is a question of the spiritual empowerment of
a young person, which is guided to finding life as meaningful through
the defiant power of the human spirit and acts of self-transcendence.
• Concentrating on the healthy aspects of an individual and the
possibilities that are still available, regardless of adversities and
handicaps that constrain a person’s life, makes it also comforting:
There is no situation without any hope, and there is no one
who could not reach for the possibility of a meaningful life
© Timo Purjo

5. OUTPUTS: DEVELOPMENT PROJECT
29
• Handbook: Hannila, P., Hoisko, S. & Juurinen, H. ”Tutkimusmatka
Tarkoitusten merellä: Tarkoituskeskeinen menetelmä nuorten
itsemurhien ehkäisemiseksi” (Exploration on the Sea of Meanings:
Meaning-Centered Method for Adolescent Suicide Prevention) *)
1. What is meant by self-destruction
2. Why an adolescent wants to die?
3. Meaning-centered approach
4. Exploration on the Sea of meanings
5. Appendices & forms
*) © 2015 Authors and Non Fighting Generation ry

5. OUTPUTS
30
3. Meaning-centered approach
a) Encountering as a holistic person
b) Values as signposts for meaningful life
c) Dialogical principles of the meaning-centered method : 3-step
model
 Commonality in every encounter
• Step 1. Concerns and reasons for dying
• Step 2. Will to live: strengths, resources and reasons for living
• Step 3. Engagement with life: towards meaningful deeds,
experiences and attitudes

5. OUTPUTS
31
4. Exploration on the Sea of meanings
 Methods that complement established approaches
 Instructions and exercises for implementing the meaning-centered
approach for professionals without logotheoretic background
 Forms  to be used during exercises
 Developed together with professionals in healthcare, youth work and
education
 Psychologists, psychiatric nurses, psychotherapists
 School social workers, school health nurses
 Teachers, study advisors
 Outreach youth workers, youth workshop workers

32
5. OUTPUTS
Exploration on the Sea
of meanings
Α. Life inventory
Value anchor
Lighthouse of hope
Reef of disappointments
Ω. Harbour of trust
Pictures © 2015 Haaja & Arwo Design Oy

33
5. LIFE INVENTORY
Review of self-destructiveness
Analysis of hopelessness, cf. existential
analysis
Opening up / feelings and emotions
 Treasure island of emotions
Opening up / thoughts
 Ask about self-destructive thoughts
 Lines of life
 Value of life -scale
At the end Life-protecting thoughts
 Reasons for living

34
5. VALUE ANCHOR
Analysis of the valuable things in life and
the life-values of the adolescent
Values as anchor protecting in hardship
and as map or compass to meaningful life
Diverse valuation system cf. doubtful and
desperate adolescents (E. Lukas)
 Ask about life-values

35
5. VALUE ANCHOR
EXERCISE 1. Valuable elements of life
EXERCISE 2. Valuable things in life
 Value-map
EXERCISE 3. Spiritual compass

EXERCISE 4. Beautiful views on the route
(cf. Meanings of the moment)

36
5. LIGHTHOUSE OF HOPE
 Ask about hope
EXERCISE 1. Visualization of hope
EXERCISE 2. Memory of hopefulness
EXERCISE 3. Hope rising from experience of
survival
EXERCISE 4. Horizon of hope

37
5. REEF OF DISAPPOINTMENTS
 Ask about disappointments
EXERCISE 1. Exploration on the island of
emotions
 Treasure island of emotions
EXERCISE 2. Becoming your own best friend
EXERCISE 3. As well on good as on bad
days
 Comic strips (Bad day, Good day, From
a bad day into a good one)
EXERCISE 4. List of meaningful alternatives

38
5. HARBOUR OF TRUST
 Ask about dreams
EXERCISE 1. Souvenirs
EXERCISE 2. Logbook of good moments
EXERCISE 3. Stream of dreams
EXERCISE 4. Meaningful narratives
 Fourfold table (Experienced difficulties
and hardship – Missed good in life –
Experienced and received good, beautiful
and valuable – Good, beautiful and
valuable that I want to experience and fulfil)

39
5. TREASURE ISLAND OF EMOTIONS

• Cf. James C. Crumbaugh & Leonard T. Maholick (1964) Purpose in
Life Test (PIL)
• Helps to specify reasons, why the adolescent wants to die or
harm himself
• 12 lines with statements at both ends. Left extreme of each line
indicates possible self-destructiveness, and right extreme indicates
experience of life’s meaningfulness. The adolescent puts a cross
(x) on the line in a place that best reflects his experiences.
• Not an actual measure (no scale), but basis for open dialogue on
concerns of the adolescent and interpretations he gives for his
own situation and experiences
40
5. LINES OF LIFE

1. Vapaa-aikani tuntuu…
tyhjältä, ilottomalta hyvältä, antoisalta
ja epätoivoiselta ja innostavalta
2. Sosiaalisissa tilanteissa…
minusta tuntuu usein, koen, että minusta
että en ole tervetullut pidetään ja kuulun
muiden seuraan osaksi porukkaa
41
5. LINES OF LIFE
X
X

1. My leisure time feels…
empty, joyless and desperate
good, rewarding and inspiring
2. In social situations…
I feel often that I’m not welcome to the company of others
It seems that I am liked and I am a part of the group
3. It seems that I am to my relatives…
only a burden; they would be better off without me
a source of joy and strength; a vital part of their lives
4. For other people…
I am totally useless
I am very important
42
5. LINES OF LIFE

5. As a girl / boy (woman / man) I feel that I am…
in some way totally wrong
okay just the way I am
6. When I face problems or adversity…
I feel that everything is falling on me and there is nothing to be done
I can trust that I’ll survive and that I get help when needed
7. When I feel bad…
I begin to dwell on and worry about everything, what is wrong in my life
I try to concentrate on meaningful things and doings
8. When I am in an intense emotional state…
I am often doing on the whim things that I regret later
I keep my head and consider carefully what I’ll do or emit
43
5. LINES OF LIFE

9. I have the feeling that…
I have no influence on my life
I am able to influence my life
10. It seems that my life is…
compulsive performing against my own will
full of possibilities from which I can choose according to my own valuations
11. If I could choose…
I would not have wanted to be born
I would not change a single day from my life
12. My future looks…
dark and hopeless
bright and hopeful
44
5. LINES OF LIFE

45
5. REASONS FOR LIVING
• Cf. Marsha M. Linehan et al. (1983) & Augustine Osman et al.
(1996) The Reasons for Living Inventory (RFL)
• Questions 1-10: personal reasons for living; values and valuations,
meanings and purposes
• Questions 11-26: life situation, e.g. family relationships and
friendships that provide grounds for living; responsibility /
responsibleness
• Questions 27-36: “lived experience”, e.g. survival beliefs that
support staying alive; hope of future

6. RESULTS: DEVELOPMENT PROJECT
• Most used tool in individual work (N=173) Lines of life -exercise
• Answers of adolescents (crosses on lines) scored afterwards by
dividing the lines in 7 sectors
• Total score thus max. 84 (12x7), grouped in 6 categories
• Among self-destructively acting adolescents (according to perception
of a piloting professional, N=45, 28%), scores centred around lower
categories and among those without self-destructiveness scores were
situated in upper categories
• Cronbach's alpha 0,9175: Internal consistency (reliability) of Lines of
life -exercise is excellent
46

• Of single statements highest correlations with total score: 10.
(0,86), 4. (0,83), 12. (0,82) and 3. (0,81)
• Highest correlation with self-destruction: statement 10.
• However qualitative value of some questions much higher than
statistical significance, e.g. 2. and 5. important for gathering of
information
47

• Well-being of the adolescents was evaluated before and after
working with the method
• 2-9 meetings
• N=15
• 5 of them signalized self-destructiveness
• WHO-5 (5-item World Health Organization Well-being Index): In
the case of four, changes were positive, with one no changes
(unchanged)
• Qualitative contribution of the method for the pilots and
adolescents much greater than can be measured by statistical
analyses
48

7. REFERENCES
• www.slideshare.net/TimoPurjo
49

8. COMMENTS AND QUESTIONS
• You may also contact me later-on…
50

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