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ABSTRACT: Youth suicide is a social issue that needs serious consideration among families, therapists and helping professionals. This article
presents an actual case of a youth who completed suicide, and discussion of the hypothetical Satir model treatment of this youth while
alive. The Satir model has numerous interventions that have current
applications toward dealing with suicidal youth in a humanist and
hopeful way, fostering youths desire to live and to become more positively involved in their lives. In the past, Satir focused on coping stances
in communication, and now the coping stances give a deeper understanding into the internal world.
KEY WORDS: adolescence; family therapy; Satir model; suicide; treatment; youth.
This article is intended to share how the Satir model (Satir, Banmen, Gerber, & Gomori, 1991) can be used to understand and treat
youth who are suicidal. Youth suicide is a major concern in Western
society, and measures need to be explored to reduce suicide among the
adolescent population. In the United States the suicide rate among
adolescents and young adults tripled between 1950 and 1980. The rate
for people 1534 years old during that time and throughout the 1990s
Wendy Lum, MA, is a Child, Youth, and Family Therapist, Kelowna, British Columbia, Canada (e-mail: welum@attglobal.net). Jim Smith, BPE, RSW, is Director of Langley
Youth & Family Services, 5569-204th Street, Langley, British Columbia, Canada V3A
1Z4. Judy Ferris, MA, MEd, is a Youth and Family Therapist, Langley Youth & Family
Services, Langley, British Columbia. Canada.
*Portions of this paper were presented at the Canadian Association for Suicide
Prevention (CASP) Conference, Vancouver, BC, October 2000.
*The authors wish to acknowledge the inspiration received from their involvement
with the Suicide Intervention & Treatment Task Force, Satir Institute of the Pacific.
Contemporary Family Therapy 24(1), March 2002 2002 Human Sciences Press, Inc.
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increasing support for the adolescents attempts at self-care, and improving the familys problem-solving behavior. A central goal is to develop an understanding within the family of the meaning of the adolescents suicidal behavior and to improve family functioning (Berman &
Jobes, 1997; Maris et al., 2000). Group therapy provides a social support
network for suicidal clients and provides a milieu where social skill
development can take place (Maris et al., 2000). Themes emerging from
group psychotherapy are family relationships, peer relationships, and
the control of potentially overwhelming feelings and impulses (Richman & Eyman, 1990).
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INNER EXPERIENCE
Behavior of the Suicidal Youth
The acting out behavior and verbal communication of suicidal
youth is an expression of his or her internal experience. The Satir
model looks at behavior and verbal communication as the result of the
inner world of youth. Through using the Satir model and by focusing
on changing adolescents internal world, destructive external behavior
has the stronger possibility of being positively changed. Satirs Personal
Iceberg Metaphor (Satir et al., 1991) acknowledges behavior as only
being a one-eighth part of the whole person, and that seven-eighths is
hidden from external view, thus the iceberg metaphor.
In dealing with suicidal youth, therapy has often been focused
more on identified behaviors. Some of these behaviors are displayed
such as running away, disruptive behavior, challenging comments and
actions, resistance to others, chronic nonattendance at school, noticeable mood changes, body movements, nonverbal responses, substance
abuse (drugs and/or alcohol), sexual acting out, giving away possessions, and verbal comments (Banmen, 2000). Suicidal teenagers have
a higher possibility of experiencing disruption and unpredictability
within their family environment (Everall, 2000). Suicidal actions or
intentions can be seen as a sign that within youths internal worlds,
there may be a sense of hopelessness, helplessness, despair, and disconnection.
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highly value themselves, but will value the other person and be aware
of the context. These teenagers live in their feelings about themselves,
others, and the world. The placating suicidal youth may experience a
deep sense of worthlessness, unworthiness, hopelessness, and helplessness. There may be behaviors that indicate depression, and a deep
unhappiness about themselves and their life. Suicidal adolescents may
reject themselves, while expecting that others have given up on them.
The rejection could manifest as a giving up on themselves, which will
inhibit their own life energy, hence possible depression. Suicidal youth
may be very unhappy and disappointed that their needs are not being
met by others (Banmen, 2000).
Suicidal youth who use the blaming stance under stress value
themselves and are aware of the context, but will not value the other
person with whom they are in a relationship. These adolescents have
high expectations of others and the world. When their expectations are
not met, a blaming stance will occur. The blaming suicidal youth may
feel a deep sense of inner isolation and loneliness. Outwardly they may
display verbal and/or non-verbal anger towards others through acting
out, bullying others, drug abuse, and delinquent behavior. These teenagers may also feel aggressive, revengeful, and indignant.
Suicidal youth who use the super reasonable stance under stress
will be focused on the context, information, and details of situations.
The super reasonable suicidal youth may feel very fragile, and have a
deep sense of isolation from others and within themselves. These youth
may create distance from others by isolating themselves with books,
games, and computers. Their behaviors may manifest outwardly through
perfectionistic, obsessive, and/or compulsive behaviors.
Suicidal youth who use the irrelevant stance under stress, have
no sense of belonging or sense of connection. Disconnection from self
can be a constant state of being. The irrelevant suicidal youth may feel
extreme pain and sensitivity. They may experience turmoil and chaos
externally and internally. They can be very impulsive, spontaneous,
and make poor choices due to their impulsive actions. These adolescents
may not be focused on tasks or not be present within their own selves.
These youth may appear to be funny, joking, and class clowns, but
internally the disconnection is extremely and deeply painful. These
teenagers may struggle with creating a sense of self or have an inability
to create a sense of self.
Adolescents are less able to access their strengths and resources
while under stressful circumstances. Suicidal youth could use any of
these coping stances, however one stance may be more prominent. Suicide
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decisions about life and death. Chandler and Lalonde (1998) found that
four out of five youth (84%) who were actively suicidal did not believe
that they had any connection to their past, present, or future. There
may be a sense that they have lost control, or have never had any
control over their world, and they may feel unable to change their
circumstances. Suicidal youth may believe that they have no choice,
or that committing suicide is the only choice that is left for them to
make. Some suicidal youth may believe that they are emotionally invisible to others and that no one will listen to them. Adolescents who are
suicidal may have had numerous losses and believe that such losses
will continue in their lives. A sense of being abandoned by others
or the world can be predominant. Suicidal youth see rejection as an
acknowledgment of their sense of being contaminated or flawed (Everall, 2000). These teenagers may believe that they are losers, and they
could be on a downward spiral in relationship to their self-esteem.
Some suicidal adolescents may believe that they are unlovable, unacceptable, or incompetent. If these teenagers or their family members
have high expectations of them, there can be a sense of failure for not
living up to being perfect or successful.
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CASE STUDY
Satir model theory regards behavior as the external manifestation
of the internal experience. Understanding behavior in this way provides
opportunity for earlier intervention into suicidal ideation. While investigating the suicide death of Paul, a pseudonym for a 16-year-old male,
Smith was initially puzzled by the lack of information to explain the
reasons for his suicide.
The information from the coroners office that Smith reviewed,
included:
1. The suicide note left by the deceased.
2. Interview narratives with the principal of the high school that
Paul last attended.
3. Attendance and disciplinary files profiles for grades kindergarten through to and including grade nine.
4. School records 1998 to January 1999.
5. Eulogy given by high school principal.
6. Interview narrative and psychological summary report of school
district psychologist.
7. Interview narratives with Pauls parents.
8. Interview narrative with teaching staff of the elementary school.
9. Psychological research questionnaire completed and provided
by the coroners agent.
In addition to the information provided by the coroners agent,
Smith conducted a telephone interview with Pauls mother to gather
birth and family system history. The suicide note contained messages
of hopelessness and helplessness. It did not explain why or how Paul
arrived at the state he was in at the time of his death. Smith wondered
what indications he may have given that might have been seen as a
precursor if not to his suicide, at least to his apparent suffering.
Through information taken from his school records (Table 1), Paul
appeared to be quiet, compliant, and academically successful. When
he reached high school he had become uncooperative, oppositional, and
bullying in his behavior with absenteeism and suspensions. He appears
to have coped with his feelings by withdrawing into himself. Adopting
a compliant coping style, as Smith suspects Paul did, prevented others
from understanding his personal internal experience.
Paul was unable to externalize his feelings of pain and/or fear.
This inability to externalize feelings, in Smiths experience, is likely
the meaning of his statement in his suicide note There is no way I
can explain what I did but it was done. I just couldnt go on living.
Smith believes that Paul lacked a deeper understanding of who he
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TABLE 1
Pauls School Records
Grade
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
(middle
school)
Grade 8
Grade 9 (3
years in
grade 9)
Days
Absent
Comments
13
Nervous, high-strung, low self-esteem.
13
25.5
27
Hesitates to ask for help in class.
Unknown With learning assistance support
achieved a B average.
05
A/B average
8.5
A/C average
35.5
Marks dropped. Achieved one B, other
marks were C, P and F. Lack of effort,
disciplinary problems, missed
assignments, disrupting others.
Unknown Several suspensions, spitting,
intimidation, fighting, using drugs at
school, extortion.
Marks continue to fall, indefinite
suspension, absenteeism, was repeating
grade nine for third time with marks
ranging from B to F with an average
of C.
already was; that in a sense Paul felt he had yet to become a person.
This expression from Pauls suicide note gives a feeling his life was not
working out and that he lacked connection with his self. This expression
from Pauls suicide note also indicates the state of despair he was in
at the time of the writing of the suicide note.
Paul succeeded academically in elementary school and appears to
have done so with the external support of his teachers. In middle-school
and high school, records show he struggled to succeed academically,
indicating he may have continued to require external support and likely
expected this support to continue as he progressed through his school
years. Without this support, his performance dropped off, as did his
compliance.
The attendance and comment profiles for grades Kindergarten
through Grade 9 as recorded by the school, are a clear indication Paul
could succeed academically when sufficiently motivated.
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Smith discovered that Paul had at times performed acts of selfmutilation by digging into his hand, and exposed skin on his arms with
a pencil or sharp instrument. Smith also discovered Paul drew pictures
depicting violence and scenes containing blood. This self-mutilation
behavior and graphic sadistic art provided another obvious opportunity
for therapeutic intervention.
The ability to understand behavior differently may be the key to
early intervention and prevention of suicide. Understanding behavior
as the external expression of an internal state sees behavior as a dynamic purposeful activity with attached expectations of self and others,
and views expectations as linked to deeper unmet universal yearnings.
These universal yearnings are directly linked to the individuals need
to evolve and, when these yearnings remain unmet, can be the experience of their life not working out.
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having Paul accept that these were his expectations. The therapist
would suggest that if Paul accepted and owned his expectations, then
he could have been more willing to fulfill his expectations and let go
of his expectations of others. Are you willing to make a decision to
stop hurting yourself, and to ease your pain? How can you let go of
expecting that they should know about your painful hurt, when you
hurt yourself? If Paul would not let go of his expectations, then the
therapist would explore the costs for him in keeping these expectations.
The therapist would suggest that he meet his own yearnings for acceptance and validation, instead of waiting for others to meet his yearnings. Together they could make a concrete plan on how Paul could
meet his yearnings. How can you extend a caring, helping hand to
yourself ? Are you willing to give yourself the gift of life, instead of
waiting for someone else to give your life to you? Is it time to let
love inside?
The facilitation of congruence, the last of the goals in the Satir
model, involves helping with the ability to be honest and truthful in
actions and words coming from ones internal experience. As clients
become more aware of interactions with self, other, and the context,
there can be the opportunity to develop congruence. Gaining an understanding of the impact of Pauls past experiences in the family and
within the school system would be very useful. What happened for
you when no one seemed to pay attention to you anymore? The therapist could also include Pauls family in family therapy, and involve his
parents or siblings in the therapeutic process. The therapist would
explore his past family experiences and past social experiences, and
then work on reducing any negative impacts in the present. Are you
still waiting for your parents to really see you? By changing how he
experienced his memories of the past, Paul could have been freer to
live his present life. Your parents gave you the gift of life, are you
now ready to accept their gift into your heart? Are you willing to
forgive your parents for not understanding you in the way that you
needed? Can you now forgive yourself for not taking better care of
yourself in the past? When Paul was not burdened by negative perceptions of himself or others, then he would have been more able to become
congruent. Can you allow yourself to live with your mistakes, without
having to punish yourself for having the courage to live?
Another important aspect of the Satir model would be reflected in
the therapists listening closely to how Paul verbalized his world and
any meaningful metaphorical words or concepts. The therapist would
closely listen to and respond with specific and intentional conscious
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responses. Are you willing to shine a warm, bright light on the part
of you that feels isolated and invisible? The pace and the tone of the
therapist would match Pauls energy level and pace in order to have
created a close therapeutic relationship and shared language.
The Satir model also encourages therapists to strengthen their
own abilities for observation of self, the client, and the context of the
session. Throughout the session, the therapist would be observing in
these three different ways. The therapist would pay close attention
to Pauls language, connection, and responses; pay attention to the
responses that he or she shared with him; and would watch his or her
own inner responses to Pauls comments and interactions.
The therapist would notice Pauls inner experience through using
the framework of the Personal Iceberg Metaphor. The therapist would
listen to, watch for and pay attention to Pauls inner experience by
using the components of the Iceberg metaphor. The therapist would
be using his or her intuition to comprehend what kind of intentional
responses might have been most effective with him. The therapist
would be watchful of his behaviors, coping, feelings, feelings about
having his initial feelings, perceptions, expectations of himself, expectations of others, expectations of his world, yearnings, and Self: I am.
The therapist could ask questions that speak to the inner components
of Pauls world. For example: (behavior) When you cut yourself, what
is the wound saying?; (coping) How do you cope with the rejection?;
(feeling) How do you feel right now as we explore this?; (feelings
about the feelings) What is the feeling that lies beneath your anger?;
(perceptions) What do you think would stop the pain?; (expectations)
What do you expect they should have done when they saw your
wounds?; (yearnings) If you were to live in that way you had hoped,
what would be happening for you instead?; (Self: I am) Can you allow
your favorite music to soothe your soul?
The therapist would look beyond Pauls initially withdrawn behaviors or his later external acting out behaviors. The transformational
experience would be more likely to occur after the therapist was able
to facilitate Pauls acceptance, acknowledgment, forgiveness, honoring,
loving, and commitment to his Self: I am. By helping to change Pauls
inner experience of himself, this would create the space for healing
and growth. The Satir model would give the therapist a map into
understanding Pauls inner experience. It can also help the therapist
to support him, to make new decisions to live, to increase his selfesteem, and support Paul to become more responsible for his life and
to encourage congruence within.
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CONCLUSION
Current treatment modalities often may address only separate
components of youths inner experience. The Satir model gives a framework that encompasses an integrative and holistic view of their inner
experience. This model can be effectively applied to the prevention,
intervention, and treatment of suicidal youth. We can now begin to
understand suicidal behavior differently by exploring and changing the
inner world of youth. Seeing suicide through new lenses allows the focus
of treatment to be internally based and transformationally focused.
The Satir model offers hope for therapists in facilitation of deep inner
transformation in youth. We need to instill hope in youth, so that they
can look forward to having a positive impact toward their future. As
more of our young people find meaning and reason in living, there will
be great hope for this and the next generation of youth.
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