Australian and New Zealand Journal of Psychiatry (1976) 10: 243
FAMILY INTERACTION AND ADOLESCENT SUICIDAL BEHAVIOUR: A PRELIMINARY INVESTIGATION* by CHRI!i"OPHER WILLIAMSt and CH3USTINA M. LYONSS
SYNOYSIS While investigators have emphasized the importance of familial relations in the production of suicidal behaviour in adolescence, experimental evaluation of specific family interaction processes has, thus far, beem neglected. The aim of the present study was to investigate possible relatiomhipe between adolescent suicidal behaviour and total on-going family functioning. Hypotheses were advanced t o evaluate the cmnmunicatio& interaction and reinforcement patterns in families. A modified revealed differences technique was employed to elicit standardized segments of interaction which were video-taped and later studied by two indepenent raters. The sample mneisted of twelve individually matched, intact family tetrads, six normal (N) and six containing an adolescent female who had exhibited suicidal behaviour (SM). Results suggest that SM families constitute a malfnnch'oning system which can be differentiated from that of n o d samples. As compared with the N group, SM f d y interaction evidenced less effective productivity, specificity, and adaptive interaction, and higher rates of conflict and negative reinfomement. Overall findings were discussed in terms of current family theory and their possible relationship to the genesis, maintenance and management of some classes of suicidal behaviour.
*Received 15 August 1975. Senior Lecturer in Clinical Psychology, University of Tasmania. SPost-Graduate Student, University of Tasmania.
INTRODUCTION There has been a marked increase in the incidence of non-fatal suicidal behaviour in recent years and it has been reported that the young, particularly the 15-24 year age group, are over represented in the statistics (Mills, et al., 1974; Weissman, 1974). Those most at risk tend to be adolescent females, with as many as 1 in every 250 of this population group engaging in suicidal behaviour (Freeman, et al., 1970). The notable rise in the incidence of selfpoisoning among girls at senior secondary school level supports this finding (Mills, et al., 1974). Many of the above group are domiciled in a family situation, intact or otherwise, and increasing credence has been given t o the opinion that the motives for youthful suicidal behaviour cannot be fully understood without a careful consideration of familial relationships (Barter, 1968; Haider, 1968). To date, support for this statement has come largely from demographic research, clinical observations and case studies. This fact is surprising in the light of the research effort in recent years, which has involved the direct study of family interaction and which has led to a considerable body of knowledge related to normal and disturbed family functioning. Thus the present investigation represents a preliminary attempt at the direct study of interaction in families containing an adolescent who has recently exhibited suicidal behaviour. RESEARCH REVIEW Family AppnwCnes With the increased emphasis o n interpersonal variables, rather than intrapsychic factors or broad societal characteristics, mounting evidence is impli-
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cating an inter-relationship between attempted suicide arid disorganization at the nuclear family level (Tuckman and Connon, 1962). Demographic surveys suggest that attempted suicide is strongly related to extreme family conflict and social disorganization (Lindsay, 1973) and note the pervasiveness of family disorganization not uncommonly extending over a number of generations (Tuckman and Connon, 1962; Tuckman and Youngman, 1964; Morrison and Collier, 1969). Haider (1968) reports that 88% of his sample of child and adolescent suicide attempters came from families which were classified as severely disturbed and disorganized. However the exact nature of these familial deficiencies has rarely been explicitly explored, with the notable exception of psychodynamically-oriented research which focuses specifically upon deviations in normal parent-child relationships rather than the family in its entirety, placing particular emphasis upon parental deprivation in child-rearing practices (Sabbath, 1969). Rosenbaum and Richman (1970, 1972) and Richman and Rosenbaum (1970a) have conducted the only major definitive theoretical study which delineates in any detail the nature of suicidal-member family processes implicating all family members. They were concerned with the specific ways in which the family structure and functions are translated into suicidal behaviour. The potential suicidal member does not initiate the pattern of interaction and communication which precipitates the act, nor is he the passive victim: he participates in a reciprocal process with other family members. A pattern of role disturbance is considered to be present in the family, and this places the suicidal member in an untenable, rigid, unchanging position of fixed status. This position is maintained by a strong intolerance for loss and separation which would be identified with any role change. Thus suicidal adolescents find it difficult, if not impossible to identify with other family members (Schrut, 1968) since their parents disallow them to test out new roles, Murphy, 1969). Emphasis has also been placed upon the suicidal individual's conflict with his parents, which becomes heightened during the often stressful period of adolescence (Jacobziner, 1960; Toolan, 1962; Tuckman and Connon, 1962; Jacobs and Teicher, 1967). Clinical research into suicidal member families points to an inadequacy of training in long term problem solving techniques. Adolescents at risk are reported to display a marked rigidity in their life style and cognitive process, being unable to consider alternative solutions (Neuringer, 1964; Leonard, 1967). Regardless of success or failure they tend to disregard all external information, maintaining an unaltered level of aspiration (Vinoda, 1966). Having set rigidly defined goals they dichotomize concepts in their environment to the extreme, seldom allowing themselves many choices, thereby increasing the probability of self-destruction as an alternative when other solutions are blocked (Hendin, 1964).
This cognitive rigidity may in fact be linked to the general rigidity of family interaction which has consistently been reported in interactional studies of disturbed families. The rigidity and the concomitant absence of adaptive techniques are considered to precipitate progressive isolation from meaningful social relationships, often producing hasty, ill-considered escape activity (Jacobs, 1967; White, 1974).
Thus in view of the current evidence it is only possible to make a generalized statement to the effect that whether adolescent suicidal potential becomes activated will depend upon the environmental situation and pattern of social and interpersonal relationships especially those involving family members. Many aspects of the reported rigidity of interaction, role and communication disturbances should be amenable to direct empirical testing and Rosenbaum and Richman (1972) have recommended that such an undertaking be attempted.
Famlly Imteracticm Research The past two decades have witnessed an upsurge in the direct, experimental study of the family as an interactive unit in its own right. Initially investigators had hoped that a family typology and an integrated theory would be developed to explain the aetiology of specific psychiatric conditions in the individual. While this has not eventuated, there are recent indications that a family typology based on a behavioural description of the most prominent maladaptive behaviour of the identified patient may not be impossible (McPherson, et al., 1973). Although initial conceptual developments in interaction research were derived from studies of families containing a schizophrenic member, more recent research has attempted t o test the generality of concepts when applied to other types of families such as those containing neurotics, delinquents and retardates (OConnor and Stakowiak, 1971), under achievers (Leighton et al., 197 l), stutterers (Allan and Williams 1974), aggressive and submissive children (McPherson et al., 1973), as well as normal populations (Ferreira, 1963). Research has led to a growing body of evidence which suggests that there may be differential interaction patterns which distinguish type8 of disturbed from nondisturbed families. However there is still doubt as to the validity of some conclusions due in part to a lack of consensus on the appropriate methodology and on the definition of experimental variables. Another current issue relates to the nature of the relationship between interaction variables and the degree of psychopathology. While Ferreira and Winter (1965) suggest that the more extreme the disorder of a family member the more extreme the measures produced, Riskin and Faunce (1970) report that on many variables normal families tend to fall in the middle range, with the problem families at either extreme, depending upon the type of disturbance present.
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CHRISTOPHER WILLIAMSA N D CHRISTINA M. LYONS Comprehensive reviews of the diverse findings of interaction research are available elsewhere (Riskin and Faunce, 1972; Jacob, 1975). In general, studies t o date have focused on variables such as the efficiency of the family group functioning, its approach to decision making, the levels of conflict, cohesion, emotionality and adaptation in interaction and the differing power structures within family systems. Family decision making processes have been the subject of many well conducted experiments. Normal families tend to be more efficient and productive in their interactions, reaching a significantly greater number of family decisions than clinic families within the same time period (Murrell and Stachowiak, 1967; O'Connor and Stachowiak, 1971). Disturbed families are considered to display difficulty in operating at a group level, frequently failing t o resolve their differences, and exhibiting greater overt and verbalized rejection (Ferreira, 1963; OConnor and Stachowiak, 1971). Mutual reciprocity in communication is often lacking in families with a disturbed member and Haley (1959) contends that such a process is related to the formation of inter-member relationships. Haley (1962) and Schuham (1970) lend support t o this contention with the finding that families with a disturbed member reveal greater difficulty in formin& coalitions (particularly those between parents) than do normal groups. The latter tend to interact in a systems-integrating manner (Alexander, 1973) in which supportive processes between parents and their children are responded to in kind, whilst in abnormal interaction, more defensive prqcedures and hostility are emitted and reciprocated (Patterson et. al., 1972). Similar tendencies have been reported to occur in families containing a suicidal adolescent (Jacobs, 1967; Richman and Rosenbaum, 1970b). Differential power structures are a more contentious area of interaction research. Haley (1962) considers the normal family as egalitarian and the disturbed as authoritarian. In contrast Stabeneau et al., (19651, Murrell and Stachowiak (1967) and Schuham (1972) consider that normal families contain one member tending towards dominance. Wynne and Singer (1963) provide a reconciliation of these findings by postulating that it is the instability of role structure in disturbed families which impedes the child's opportunity to test a variety of roles during development. In relation to suicidal behaviour, disturbed role functioning has been noted in clinical studies of suicidal member families (Murphy, 1969; Richman and Rosenbaum, 1970a; Schrut, 1968). A number of variables related to intra-familial communication have been found to be sensitive indices of disturbed family functioning with the latter group displaying a greater number of ambiguous and general statements than controls (Lamson, 1969). A series of studies by Ferreira (1963), OConnor and Stachowiak (1971) and Stachowiak
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(1967), reveal a more open style of communication and greater agreement among normal family members as compared to disturbed families. Defensive messages, as observed in disturbed family functioning, are considered to impair symbolic functioning and sex role identification in the child (Becker et al., 1965). Suicidal member families are also considered to manifest these disturbed communication patterns in which adaptive channels are blocked (Jacobs and Teicher, 1967; Schrut, 1968). It has been reported that suicidal adolescents frequently exhibit communication patterns characterized by a chronic lack of involvement in interaction and an inability to express needs in a manner which leads to their gratification (Fawcett, et al., 1969). As a result family relationships are often confused or distorted and attempts at a meaningful exchange of ideas and a possible resolution of problems are ineffective (Jacobs, 1967; Richman and Rosenbaum, 1970b). Consequently the study of effectiveness of communication in families with a suicidal adolescent warrants further attention.
Learning Approaches In the light of the rapid development of the principles and procedures of behaviour modification, it is surprising that few systematic attempts have been made to integrate \data on suicidal behaviour into a learning theory. Frederick and Resnik (1971) note that it would be extremely difficult to explain self-destructive behaviours without employing learning principles. One of the earliest attempts to integrate data on suicidal behaviour and learning theory is represented by the simplistic drive reduction theory (Gr& and Mallin, 1967), where tension reduction contingent on the act is viewed as a reinforcing consequence which may effect the future repetition of the behaviour. A related interpretation of suicidal behaviour delineated by Lukianowicz (1972) and others, interprets the act as a learned avoidance response facilitating withdrawal from a temporarily intolerable situation. To date there is little empirical support for the widespread occurrence of this mechanism and the theory fails to adequately explain why this particular form of behaviour is originally chosen by the individual. A third learning hypothesis is that which considers the act to be acquired through vicarious imitation or modelling. The escalation of rates has been found to be greatest in areas already carrying high rates (Mills, et al., 1974), whilst other research reveals that up t o half the cases of adolescent suicidal behaviour have had direct contact with others exhibiting the behaviour, with a particularly high incidence in the family history. (Teicher and Jacobs, 1966; Rosenbaum and Richman, 1972). Thus experience of others exhibiting this pattern may lessen constraints against it. This modelling hypothesis does have explanatory strength in that it can account for the fact that the individual
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selects suicidal behaviour in the first place. It is further supported by the observation that suicidal behaviour may exhibit a contagion effect (Matthews, 1968). A final learning interpretation of aspects of suicidal behaviour is that based on the operant paradigm (Bostock and Williams, 1974, 1975). Studies emphasizing the consequent events of suicidal behaviour have given increased credence to the conceptualization of the behaviour as an attempt to modify or control the immediate environment (Rubenstein et al., 1958; Sifneos, 1966; Fawcett et al., 1969). It is considered that the consequent interpersonal interactions following suicidal behaviour, in some instances, reinforce and maintain the behaviour (Sale, et al., 1975). Even if the act is not originally designed to modify the environment, the contingent positive or negative consequences may still in fact reinforce the behaviour and contribute to its maintenance (Sifneos, 1966). The application of operant principles to the understanding and modification of maladaptive behaviour of children in family settings has been well documented (Patterson, et al., 1972). Often suicidal threats or gestures compel parents to acquiesce to their offspring, giving favoured treatment over other siblings (Lennard-Jones and Asher, 1959; Lukianowicz, 1972). Thus an investigation of reinforcement patterns in families may lead to fruitful explanatory and treatment implications.
METHOD The following predictions, based on the literature concerned with the interaction and communication patterns in disturbed families, are put forward for examination. As compared with the N group, the SM group interaction will evidence: (i) less effective productivity (total productivity being defined as the percentage of discrete effective and constructive speeches per total number of speeches), (ii) more conflict (total conflict being defined as the number of disagreements, interruptions and non-supportive simultaneous speeches), (iii) less adaptation (adaptation being defined as changes in member opinion in the direction of consensus), (iv) a significantly different pattern of role dominance (individual member role dominance being defined as the number of times a member speaks to and is addressed by others, plus the number of times an isolate decision is upheld), (v) less specificity (total specificity being defined as the number of speeches specifically addressed to a particular member). The following predictions are based o n behavioural theory which postulates that differential intrafamilial patterns of reinforcement may be related
to the development and maintenance of some classes of suicidal behaviour. (vi) There will be less supportive and more nonsupportive contingent speeches in SM family interaction as compared with N group interaction (supportive speeches being positive statements contingent upon a member’s response and expressing warmth, approval, interest and empathy: non-supportive speeches being negative statements contingent upon the previous response and indicating disapproval, disagreement or rejection of that response), (vii) there will be significant differences in the levels of positive and negative consequences emitted and received by each member of the SM family (positive consequences being agreement plus verbal and non-verbal expressions of approval, support or interest contingent upon the member’s speech: negative consequences being verbal or non-verbal behaviour indicating disagreement, disapproval, inattention and boredom contingent upon the member’s speech), (viii) there will be significant differences between the levels of positive and negative consequences received by each member of the SM family.
Subjects The sample consisted of a total of twelve family groups, six comprising the experimental group and six the control group. Each family had to consist of at least four members - mother, father, a female adolescent and one other sibling over the age of 8 years: with all four members having lived as an intact nuclear family for at least five uninterrupted years prior to the present study. No nonfamily member was to be present in the household. The suicidal member (SM) group consisted of families in which an adolescent female sibling, within the specified age range of 12-18 years inclusive, had presented for the first time at a general hospital following a drug overdose. Families meeting the general criteria were screened for evidence of psychiatric treatment for other family members and for evidence of psychosis in the suicidal adolescent. Neither the suicidal adolescent nor her family were to be engaged in on-going psychiatric treatment. The control or normal (N) group which consisted of families whose members had never received any form of psychiatric treatment, were individually matched with the SM group on the following variables which have been shown to bear a significant relationship t o interaction processes: nuclear family size, number of years of marriage, age of all members, sex and birth order of siblings, educational level, occupation and socio-economic status of the parents, and religion.
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CHRISTOPHER WILLIAMS AND CHRISTINA M. LYONS Procedure After initial contact, families were requested to attend a teaching hospital where a comfortable room was available for use. A remote control camera used for videotaping the interaction was placed inconspicuously in a far corner and was monitored from an adjacent, sound-proofed room. Procedural aspects and the time of day of observations were standardized. The SM group were videotaped between 3 and 4 weeks after the initial presentation. The method employed to elicit interaction was based on a modification of Strodtbeck's (1951) revealed differences technique. This method entails families being confronted with a hypothetical problem situation which they are requested to discuss in an attempt to decide on an alternative which best represents the thinking of the family as a whole. Eight items were selected for discussion from a questionnaire concerned with hypothetical problem situations related to family relationships. Prior to the discussion segments each family member privately responded to the questionnaire. Questionnaire items used to elicit discussion were those on which three of the four members agreed. Each family member had equal exposure as the isolate in the tetrad. In contrast to-the standard revealed differences method. the present procedure required that members neither be informed that their opinions differed nor be asked to reveal their individual attitudes. This unrevealed differences form is considered to produce a less contrived interaction. Six of the eight items were recorded, the first two items functioned as buffer items to allow the family to settle into interaction in as natural a vein as possible. This practice is undertaken as many researchers assume that after a short settling period, laboratory family interaction becomes more analogous to that observed in the naturalistic setting (Misher and Waxler, 1968). Rating codes were made as objective as possible in order to diminish error and two trained psychologists independently rated the interaction segments.
RESULTS Spearman Rank-Order correlation coefficients were computed between raters on the ranks of the various codes for each discussion. The resultant correlations ranged from 0.60 to 0.99, with a mean of 0.86. Results relating to the first group of hypotheses, those concerned with the efficiency and productiveness of family functioning, reveal a clear trend. The N families produced a significantly higher rate of effective speeches than the SM families (t = 7.046, d.f. = 5, p p >0.01). The third hypothesis was related to adaptation scores which were derived from the relationship between the number of pair differences in initial opinion and the number existing after family discussion. The N group had significantly higher scores than the SM group, indicating a higher level of eventual concensus despite initial differences (t = 17.101, d.f. = 5, p 0.05). Furthermore, no significant differences resulted when the dominance of individual members of the N family was compared with the respective member scores from the SM family group. While the percentage scores of total dominance for each member illustrated a hierarchical patterning in both groups of families, a number of descriptive trends are worthy of note. As compared with the N family group, role dominance was less evenly distributed between the SM group parents, and the SM sibling assumed greater relative dominance than her control sibling. The fifth hypothesis proposed that the interaction of SM families will be less specific than that of control families. While both groups gained high scores on this measure, the normal families specifically addressed a greater number of speeches to members (representing 75.96% of total productivity) than did SM families (69.07% of total speeches emitted being specific). The difference between the two groups on the specificity measure was statistically significant (t = 2.317, d.f. = 5, 0.05> p >0.025). The second group of hypotheses were concerned with the inference that differential patterns of reinforcement may be operating in the two groups of families. It was predicted that the SM group interaction would contain less supportive and more nonsupportive contingent speeches as compared with the N group interaction. The N group generated a significantly higher proportion of positive contingent statements (61.05%) as compared with the SM family group (21.39%). The difference was statistically significant ( t = 4.392, d.f. = 5, p p >0.005). A further hypothesis related to the proposed Operant component of interaction stated that each member of the SM group will emit and receive different rates of positive and negative consequences. Upon examination of the mean total proportion of reinforcement emitted and received by each member, several trends emerge. Both the SM and her sibling
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received a greater, though non-significant rate of positive consequences than they emitted (SM: t = 2.988, d.f. =3, p >0.05; Sibling: t = 2.188, d.f. = 3, p >0.05). The reverse pattern held for parents, both of whom dispensed more support than they received. This difference however, was not d.f. = 3, statistically significant (t = 2.775, p >0.05). For no member did the proportion of negative reinforcement emitted and received vary more than could be expected by chance. It was finally hypothesized that members of the SM family group would be differentiated by the rate of positive and negative consequences they receive. Kruskal-Wallis one-way analyses of variance were performed comparing each member. The rate of positive effect received per speech emitted did not differ significantly between members of the SM family group (H = 3.50, d.f. = 4, 4, 4, p >0.05). However the rate of negative consequences received per speech emitted did significantly discriminate between the three members (H = 5.69, d.f. = 4, 4, 4, p 0.001).
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DISCUSSION An examination of the overall results suggests that aspects of suicidal behaviour in adolescent females may bear a relationship to the social psychological properties of the nuclear family unit. Consonant with the specific predictions of interaction theory, the SM families displayed a significantly different pattern of functioning than that of N families: a pattern generally considered to be indicative of disturbance. This general conclusion lends confirmation to the findings of a wide range of clinical and epidemiological studies that implicate disturbances at the nuclear family level with some classes of suicidal behaviour (Tuckman and Connon, 1962; Haider, 1968; Rosenbaum and Richman 1970, 1972; Teicher, 1970; McCulloch and Philip, 1972; White, 1974). Interaction and Communication Patterns Related to the efficiency of the family group in its approach to decision making and the resolution of disagreements is the measure of effective productivity (Stachowiak, 1967). Whilst the N group interacted at a high level of effectiveness communicating many relevant statements, only approximately one third of the total productivity of SM families was coded as being efficient. A considerable proportion of their speeches were conflictual, uttered simultaneously, or unrelated to the discussion topic. Thus the SM families’ members were less able to communicate clearly and effectively in terms of content and interpersonal interaction. This finding is consistent with that related to other types of disturbed
families (Vandenberg and Stachowiak, 1966; MurrelI and Stachowiak, 1967). It is. considered that low effective productivity and minimd information sharing is indicative of rigid, disturbed family interaction (Riskin and Faunce, 1970). It is conceivable that the inability of some suicidal adolescents to emit and receive meaningful verbal communication (Graff and Mallin, 1967; Fawcett et al., 1969) may originate in such defective family functioning. Another measure related to the adjustment of family members is the level of conflict displayed in interaction (Murrell and Stachowiak, 1967). The significantly higher proportion of conflict in the SM family group resulted in discussions which were more fragmented and disorderly than those of N families with a relatively high rate of interruptions and simultaneous speeches. Similar patterns have been shown to characterize the interaction of disturbed families (Fisher et al., 1959; OConnor, 1967) and the findings are consistent with the clinical observations recording extreme dissension and disruption in interpersonal relationships in families containing a suicidal member (Teicher, 1970; McCulloch and Philip, 1967). It is of interest to note that on a descriptive level, the SM adolescent engaged in conflictual interaction with either or both of her parents, but displayed little conflict with her sibling. This tendency is consistent with that noted by Jacobziner (1960) and Tuckman and Connon (1962). Such disturbed parent-child relationships have frequently been cited as an important factor in families containing a suicidal member (Sabbath, 1969). The possible ramifications of such conflict for the suicidal adalescent are the deterioration of interpersonal relationships (Teicher, 1970; McCulloch and Philip, 1972) often leading to estrangement, progressive isolation (Sabbath, 1969; Jacobs, 1967) and an inability to cope effectively with problem situations. The interaction code of adaptation is hypothesized to be one of the factors involved in the development of intra unit structure which allows the family group to maintain itself as a consolidated system over time. Specifically the measure taps the ability of members to adjust and to cope with initial conflicts. The present finding that families with a disturbed member experience difficulty in reaching an efficient group decision has also been noted by Haley (1963) who suggests that the level of adaptation achieved by the family as a whole is related to the level of adjustment of the individual members. Realistic adaptation as displayed by N families is considered to be facilitated by the identification of specific view points, a mutual respect €or differences and constructive conflict resolution (Fisher, et al., 1959). The results indicate that as compared to N families, SM family interaction contained low rates of these behaviours. The resultant impaired problemsolving ability may also be related to the high level of conflict found in the interaction, as the SM families appeared to lack the ability to overcome dissension. White ( 1974) has attributed adolescent
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CHRISTOPHER WILLIAMS A N D CHRISTINA M. LYONS suicidal behaviour in part to the modelling of faulty problem-solving techniques designed to cope with stress.
In relation to the structural interactional variable of familial power relations or role dominance, the evidence is more ambiguous. The failure of disturbed families to adapt work together to overcome difficulties has been postulated to be due, in part, to an absence of parental influence, or a struggle for power (Murrell and Stachowiak, 1967). While a tendency towards ineffective leadership was noted in the dominance patterns of the SM family group, the measure failed to discriminate significantly between the two classes of families. As wide variability was noted for each class of families, it may be that this measure is not appropriate to tap the uniqueness of the integral structure of each family entity. Haley (1972) has reported that measures of process (conflict and specificity) and of outcome (productivity and adaptation) are generally superior to those such as role dominance which are related to family structure. The final interactional measure, that related to the specificity of communication, yielded significant results. Although a large proportion of family speeches in both groups were directed to individual members, specificity of address in the SM group was still significantly less than that of the N group. Thus they displayed a more general tendency in communication in a manner similar to that noted in other maladjusted families (O’Connor and Stachowiak, 1971; Stachowiak, 1967; Lamson, 1969). The relatively high rate of specificity may be related to the open hostility and conflict frequently reported to occur between SM family members. McPherson et al., (1973) reported a similar strong overtness and directness of communication in families with a behaviourally disturbed adolescent. Indices such as low productivity, specificity and adaptation. and high conflict, as noted in SM family functioning, are considered to be definitive of marked rigidity in interaction. This rigid adherance to stereotyped and ineffectual patterns of interaction has been reported to occur in a wide range of disturbed family groups and is considered by many theorists to be the hallmark of disturbed functioning (Haley, 1963). A considerable body of diverse research into suicidal behaviour does offer some support for this general contention. A marked rigidity in the life style and cognitive operations has been observed in several investigations (Neuringer, 1964; Leonard, 1967). It is considered that when faced with a problem the high risk individual tends to disregard external stimuli, adhering to rigidly defined goals and thus effectively blocking other solutions (Hendin, 1964; Vinoda, 1966). In the face of such a paucity of alternatives the suicide attempt may become a form of coping behaviour. A similar crisis intolerance (Richman and Rosenbaum, 1970a) or destructive and disintegrative
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reactions to stress situations have been found to characterize families with a disturbed member (Alexander, 1973). It may in fact be, as White (1 974) has postulated, that the rigid problem-solving behaviour of the suicidal individual is acquired through exposure to a similar rigid problem-solving pattern operating in the total family situation. Reinforcement Patterns The data do supply some preliminary support for the proposal that certain classes of suicidal acts may constitute a maladaptive behaviour pattern under the control of social stimuli and reinforcemenl (Frederick and Resnik, 1971; Bostock and Williams, 1974, 1975). The SM family evidenced fewer positive and greater negative contingent consequences than the control group. At an observational level SM families appeared less consistent in the type of contingent support given and this ten: dency coupled with the relatively low rate of positive contingent support may have mitigated against the facilitation of more adaptive behaviourr necessary for mutual co-operation. These findings may be interpreted in terms of the tendency noted in other maladjusted families by Patterson et al., (1972) and Alexander (1973). Elevated levels of negative support have been observed to produce in return more defensive, non-supportive communications, thus further increasing deviant-amplifying behaviours. The rates of positive and negative consequences dispensed in SM family interaction have further significance in the light of the proposition that supportive emotional messages are considered to play a vital role in the process of maintaining family solidarity, unity and cohesion (Vandenberg and Stachowiak, 1966; O’Connor and Stachowiak, 1971). It is conceptualized that such expressiveness is necessary to facilitate integrative relationships between members and to regulate tension levels. Thus it may be that the relatively low amount of positive consequences expressed by SM families was insufficient to promote a congenial cohesive atmosphere and reduce conflict. At any rate, other studies have confirmed the present observation of high rates of non-supportive or hostile affect in the interpersonal relationships of families containing adolescent suicide attempters (Vinoda, 1966; Richman and Rosenbaum, 1970a, 1970b; Connell, 1972). Few differences in the rate of consequences emitted to those received discriminated between SM family members at a significant level. This may have been due in part to the small sample of results available for this measure, but nevertheless certain trends did emerge. When data were n o m e d for participation effects, the SM received higher rates of both forms of consequences than did others. An analysis of family interaction by Patterson et al., (1972) reported similar rich reinforcement schedules dispensed to deviant boys. While the parental couple tended to send more positive support to their children than they received
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in turn, both the SM and her sibling were in receipt of a higher rate of positive consequences. The SM secured the highest rate of rewarding consequences relative to her output. Reid (1969) has reported that the more supportive consequences a disturbed child receives relative to the rate he emits per unit of interaction, the more he is likely to respond with coercive and deviant behaviour. Such a relationship between the deviation in reciprocity of positive rewards and the output of maladaptive behaviour may bear investigation in relation to some classes of adolescent suicidal behaviour. Although the SM was most efficient in gaining reward from interaction, she also received a significantly greater rate of negative consequences than her sibling, indicating that only the sibling was in receipt of consistent positive support for his or her behavioar. Such a differential pattern of reinforcement dispensed to each child may be related to the occurrence of behaviours related to attempted suicide. It has been suggested that this maladaptive response is used by the SM as a tactic for the securing of greater overall support and for modifying such relationships in her favour (Lukianowicz, 1972; White, 1974). While these contentions require further specific investigation, the relevance of the differential reinforcement pattern noted for the SM is underscored by reports that parents have been observed unintentionally to eliminate adaptive repertoires available to the suicidal adolescents (Jacobs, 1967).
CONCLUSION The findings of the present investigation suggest that the functioning of families containing a sibling who has engaged in self-poisoning differs significantly from that of normals. Specifically, it has been argued that impaired interaction, ineffective communication and inappropriate reinforcement contingencies may in fact be related to the genesis and maintenance of some classes of suicidal behaviour. However, considerable caution must be attached to the interpretation of these preliminary results. Methodological problems in family interaction research necessitated the use of a small, rigorously controlled sample and consequently generalization to the wider community of attempted suicides is not warranted. The further problem of the generalization from interaction samples to family behaviour in general has been outlined, and the final caution relates to the cross-sectional, retrospective nature of the study: a problem common to the bulk of research into suicidal behaviour. However it is argued that the direct, objective study of family interaction and adolescent suicidal behaviour will add valuable data to clinical and epidemiological studies. While the interpretation of each specific interaction measure is clearly most complex (Safilios-Rothschild, 1970), the methodology should allow adequate comparison across samples. Research findings to date suggest that on
certain measures family members engage in consistent patterns of interaction which remain comparatively stable over time and across situations (Ferreira and Winter, 1966; 'Murrell and Stachowiak, 1967). Furthermore, certain measures do differentiate families with a disturbed sibling from normal groups, and finally increasing evidence has demonstrated that therapeutic change can be brought about in one member when such measures are modified at the level of total family functioning (Alexander and Parsons, 1973; Patterson et al., 1972; Stuart, 1971). Consequently the systematic and objective study of family interaction should add to the understanding and management of adolescent suicidal behaviour.
REFERENCES Alexander, J. (1973). Defensive and supportive communications in normal and deviant families. Journal of Consulring and Clinical Psyclrology, 40: 223. Alexander, J. and Parsons, B. (1973). Short term behavioural intervention with delinquent families. Journal of Abnormal Psychology, 81: 219. Allan, F. and Williams, C. L. (1974). Interaction patterns in families containing a stuttering sibling. Australian Journal of Human Communication Disorders, 2: 87. Barter, J. (1969). Adolescent suicide attempts: a follow-up study of hospitalized patients. Archives of General Psychiatry, 12: 213. Becker, J., Tatsuaka, M. and Carlson, A. (1965). The communicative value of parental speech in families with disturbed children. Journal of Nervouh and Menial Disease, 141: 359. Bostock, T. and Williams, C. L. (1974). Attempted suicide as an operant behaviour. Archives of General Psychiatry, 31: 482. Bostock, T. and Williams, C. L. (1975). Attempted suicide: An operant formulation. Ausiralian and New Zeulund Journal of Psychiairy, 9: 107. Connell, H. (1972). Attempted suicide in school children. Medical Journal of Australiu, 1: 686. Fawcett, J., Leff, M. and Bunney, W. E. (1969). Suicide: Clues from interpersonal communication. Archives of General Psychiairy, 21: 129. Ferreira, A. (1963). Decision making in normal and pathologic families. Archives of General Psychiatry, 8: 68. Ferreira, A. and Winter, W. (1965). Family interaction and decision making. Archives of General Psychiatry, 13: 214. Ferreira, A. J. and Winter, W. D. (1965). Stability of interactional variables in family decision-making. Archives of General Psychiatry, 14: 352. Fisher, S., Boyd, l., Walker, D. and Sheer, D. (1959). Parents of schizophrenics, neurotics and normals. Archives of General Psychiairy, 1: 149.
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CHRISTOPHER WILLIAMS A N D CHRISTINA M. LYONS Frederick, C. J. and Resnik, H. L. P. (1971). How suicidal behaviors are learned. American Journal of Psychotherapy, 25: 37. Freeman, J., Ryan, C. and Beattie, R. (1970). Epidemiology of drug overdosage in Southern Tasmania. Medical Journal of Australia, 2: 1168. Graff, H. and Mallin, R. (1967). The syndrome of the wrist cutter. American Journal of Psychiatry, 124: 36. Haider, I. (1968). Suicidal attempts in children and adolescents. Briiislr Journal of Psychiatry, 114: 1133. Haley, J. (1959). The family of the schizophrenic: A model system. Journal of Nervous and Mental Disease, 129: 357. Haley, J. (1962). Family experiments: A new type of experimentation. Family Process, 2: 265. Haley, J. (1963). Strategies of Psychotherapy. Grune and Stratton, New York. Haley, J. (1972). Critical overview of the present status family interaction research in Family Interaction: A Dialogue Between Family Researchers and Family Therapists (Ed. Framo, J.) Springer Publishing, New York. Hendin, H. (1964). Suicide and Scandinavia. Grune and Stratton, New York. Jacob, T. (1975). Family interaction in disturbed and normal families: A methodological and substantive review. Psychological Bulletin, 82: 33. Jacobs, J. (1967). Adolescent suicide attempts: The culinination of progressive social isolation. Unpublished doctoral dissertation, University of California. Jacobs, J. and Teicher, J. D. (1967). Broken homes and social isolation in attempted suicides of adolescents. lniernational Journal of Social Psychiatry, 13: 139. Jacobziner, H. (1960). Attempted suicides in children. Journal of Pediatrics, 56: 519. Lamson, A. (1969). Communication in families with a schizophrenic offspring and in normal families. Unpublished doctoral dissertation, Boston University. Leighton, L., Stollak, G. and Fergusson, L. (1971). Patterns of communication in normal and clinic families. Journal of Consulting and Clinical Psychology, 36: 252. Leonard, C. (1967). Understanding und Preventing Suicide, Charles C. Thomas, Springfield. Lennard-Jones, J. they do it: A 1138. Lindsay, J. S. B. area. The New
and Asher, R. (1959). W h y do study of pseudocide. Lancet, 1: (1973). Suicide in the Auckland Zealand Medical Journal, 77: 149.
Luckianowicz, N. (1972). Suicidal behaviour - an attempt to modify the environment. British Journal of Psychiairy, 121: 387.
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Matthews, P. C. (1968). Epidemic self-injury in an adolescent unit. International Journal of Social Psychiatry, 14: 125. McCulloch, J. W. and Philip, A. E. (1967). Social factors associated with attempted suicide: a review of the literature. British Journal of Psychiairic Social Work. 9: 30. McCulloch, J. W. and Philip, A. E. (1972). Suicidal Behaviuur. Pergamon Press, Oxford. McPherson, S., Goldstein, M. and Rodnick, E. (1973). Who listens? Who communicates? How? Styles of interaction among parents and their disturbed adolescent children. Archives of General Psychiatry, 28: 393. Mills, J., Williams, C. L., Sale, I., Perkin, G . and Henderson, S. (1974). The epidemiology of selfpoisoning in Hobart, 1968-1972. Australr~n trnd New Zealand Journal of Psychiairy, 8: 167. Mishler, E. and Waxler, N. (1968). Interaciion in Families. Wiley, New York. Morrison, G. and Collier, J. (1969). Family treatment approaches to suicidal children and adolescents. Journal of the American Academy of Child Psychiatry, 8: 140. Murphy, V. (1969). Personality and the nature of suicide attempts. British Journal of Psychiatry, 115: 791. Murrell, S. A. and Stachowiak, J. G. (1967). Consistency, rigidity and power in the interaction patterns of clinic and non-clinic families. Journal of Abnormal Psychology, 72: 265. Neuringer, C. (1964). Rigid thinking in suicidal individuals. Journal of Consulting and Clinicd Psychology, 28: 54. OConnor, W. A. and Stachowiak, J. G. (1971). Patterns of interaction in families with high adjusted, low adjusted, and mentally retarded members. Family Process, 10: 229. Patterson, G. R., Cobb, J. and Ray, R. (1972) .4 social engineering technology for retraining the families of aggressive boys, in Issues and Trends in Behaviorrr Therapy. (eds. Adams, H. E. and Unikel, I. P.) Charles C. Thomas, Illinois. Reid, J. B. (1969). Reciprocity in family interaction. Unpublished doctoral dissertation, University of Oregon. Richman, J. and Rosenbaum, M. (1970a). The family doctor and the suicidal family. Psychiatry in Medicine, 1: 27. Richman, J. and Rosenbaum, M. (1970b). A clinical study of the role of hostility and death wishes by the family and society in suicidal attempts. Israel Annals of Psychiatry and Related Disciplines, 8: 213. Riskin, J. and Faunce, E. (1970). Family interaction scales. Archives of General Psychiatry, 22: 504. Riskin, J. and Faunce, E. (1972). An evaluative review of family interaction research. Fumily Process, 11: 365.
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Rosenbaum, M. and Richman, J. (1970). Suicide: The role of hostility and death wishes from the family and significant others. American Journal of Psychiatry, 126: 128. Rosenbaum, M. and Richman, J. (1972). Family dynamics and drug overdoses. Life-Threatening Behaviour, 2: 19. Rubenstein, R., Moses, B. and Lidz, T. (1958). On attempted suicide. Archives of Neurology and Psychiatry, 79: 103. Sabbath, J. (1969). The suicidal adolescent - the expendable child. Journal of the American Academy of Child Psychiatry, 8: 272. Safilios-Rothschild, C. (1970). The study of family power structure: A review 1960-1969. Journal of Marriage and the Family, 32: 539. Sale, I., Williams, C. L., Clark, J. and Mills, J. ( 1975). Suicidal Behaviour: Community Attitudes and Beliefs. Suicide, 5: 158. Schrut, A. (1968). Some typical patterns in the behaviour and background of adolescent girls who attempt suicide. American Journal of Piychialry, 125: 107. Schuham, A. (1970). Power relations in emotionally disturbed and normal family triads. Journal of Abnormal Psychology, 75: 30. Schuham, A. (1972). Activity, talking time and spontaneous agreement in disturbed and normal family interaction. Journal of Abnormal Psychology, 79: 68. Sifneos, P. ( 1966). Manipulative suicide. Psychiatric Quurterly, 40: 525. Stabenau, J. R., Tupin, J., Werner, M., and Pollin, W. D. (1965). A comparative study of families of schizophrenics, delinquents and normals. Psychiatry, 28: 45. Stachowiak, J. G. (1967). The study of verbal interactions in disturbed and normal families: The reciprocal impact of parents and children. Paper presented at the Groves Conference on the Family, San Juan, Puerto Rico.
Strodtbeck, F. L. (1951). Husband-wife interaction over revealed differences. American Sociological Review, 16: 468. Stuart, R. B. (1971). Assessment and change of the communicational patterns of juvenile delinquents and their parents, in Advances in Behaviour Therapy. (eds. Rubin, R. D., Fensterheim, H., Lazarus, A. A. and Franks, C. M.) Academic Press, New York. Teicher, J. D. (1970). Children and adolescents who attempt suicide Paediatric Clinics o f North America, 17: 687. Teicher, J. D. and Jacobs, J. (1966). Adolescents who attempt suicide: Preliminary findings. American Journal o f Psychiatry, 122: 1248. Toolan, I. M. ( 1962). Suicide and suicidal attempts in children and adolescents. American Journal of Psychiatry, 118: 719. Tuckman, J. and Connon, H. E. (1962). Attempted suicide in adolescents. American Journal of Psychiatry, 119: 228. Tuckman, J. and Youngman, W. F. (1964). Attempted suicide and family disorganization. Journal of Genetic Psychology, 105: 187. Vandenberg, G. and Stachowiak, J. G . (1966). Patterns of conflict and dominance in family interaction. Paper read at the Midwestern Psychological Association Meeting, Chicago. Vinoda, K. (1966). Personality characteristics of attempted suicides. British Journal o f Psychiatry, 112: 1143. Watzlawick, P., Beavin, J., Sikorski, L., and Mecia, B. (1970). Projection and scapegoating in pathological families. Family Process, 9 27. Weissman, M. M. (1974). The epidemiology of suicide attempts, 1960-1971. Archives of General Psychiatry, 30: 737. White, H. C. (1974). Self-poisoning in adolescents. British Journal of Psychiatry, 12k 24. Wynne, L. C. and Singer, M. T. (1963). Thought disorder and family relations of schizophrenics. Archives o f General Psychiatry, 9: 191.
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FAMILY INTERACTION AND ADOLESCENT SUICIDAL BEHAVIOUR: A PRELIMINARY INVESTIGATION* by CHRI!i"OPHER WILLIAMSt and CH3USTINA M. LYONSS
SYNOYSIS While investigators have emphasized the importance of familial relations in the production of suicidal behaviour in adolescence, experimental evaluation of specific family interaction processes has, thus far, beem neglected. The aim of the present study was to investigate possible relatiomhipe between adolescent suicidal behaviour and total on-going family functioning. Hypotheses were advanced t o evaluate the cmnmunicatio& interaction and reinforcement patterns in families. A modified revealed differences technique was employed to elicit standardized segments of interaction which were video-taped and later studied by two indepenent raters. The sample mneisted of twelve individually matched, intact family tetrads, six normal (N) and six containing an adolescent female who had exhibited suicidal behaviour (SM). Results suggest that SM families constitute a malfnnch'oning system which can be differentiated from that of n o d samples. As compared with the N group, SM f d y interaction evidenced less effective productivity, specificity, and adaptive interaction, and higher rates of conflict and negative reinfomement. Overall findings were discussed in terms of current family theory and their possible relationship to the genesis, maintenance and management of some classes of suicidal behaviour.
*Received 15 August 1975. Senior Lecturer in Clinical Psychology, University of Tasmania. SPost-Graduate Student, University of Tasmania.
INTRODUCTION There has been a marked increase in the incidence of non-fatal suicidal behaviour in recent years and it has been reported that the young, particularly the 15-24 year age group, are over represented in the statistics (Mills, et al., 1974; Weissman, 1974). Those most at risk tend to be adolescent females, with as many as 1 in every 250 of this population group engaging in suicidal behaviour (Freeman, et al., 1970). The notable rise in the incidence of selfpoisoning among girls at senior secondary school level supports this finding (Mills, et al., 1974). Many of the above group are domiciled in a family situation, intact or otherwise, and increasing credence has been given t o the opinion that the motives for youthful suicidal behaviour cannot be fully understood without a careful consideration of familial relationships (Barter, 1968; Haider, 1968). To date, support for this statement has come largely from demographic research, clinical observations and case studies. This fact is surprising in the light of the research effort in recent years, which has involved the direct study of family interaction and which has led to a considerable body of knowledge related to normal and disturbed family functioning. Thus the present investigation represents a preliminary attempt at the direct study of interaction in families containing an adolescent who has recently exhibited suicidal behaviour. RESEARCH REVIEW Family AppnwCnes With the increased emphasis o n interpersonal variables, rather than intrapsychic factors or broad societal characteristics, mounting evidence is impli-
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cating an inter-relationship between attempted suicide arid disorganization at the nuclear family level (Tuckman and Connon, 1962). Demographic surveys suggest that attempted suicide is strongly related to extreme family conflict and social disorganization (Lindsay, 1973) and note the pervasiveness of family disorganization not uncommonly extending over a number of generations (Tuckman and Connon, 1962; Tuckman and Youngman, 1964; Morrison and Collier, 1969). Haider (1968) reports that 88% of his sample of child and adolescent suicide attempters came from families which were classified as severely disturbed and disorganized. However the exact nature of these familial deficiencies has rarely been explicitly explored, with the notable exception of psychodynamically-oriented research which focuses specifically upon deviations in normal parent-child relationships rather than the family in its entirety, placing particular emphasis upon parental deprivation in child-rearing practices (Sabbath, 1969). Rosenbaum and Richman (1970, 1972) and Richman and Rosenbaum (1970a) have conducted the only major definitive theoretical study which delineates in any detail the nature of suicidal-member family processes implicating all family members. They were concerned with the specific ways in which the family structure and functions are translated into suicidal behaviour. The potential suicidal member does not initiate the pattern of interaction and communication which precipitates the act, nor is he the passive victim: he participates in a reciprocal process with other family members. A pattern of role disturbance is considered to be present in the family, and this places the suicidal member in an untenable, rigid, unchanging position of fixed status. This position is maintained by a strong intolerance for loss and separation which would be identified with any role change. Thus suicidal adolescents find it difficult, if not impossible to identify with other family members (Schrut, 1968) since their parents disallow them to test out new roles, Murphy, 1969). Emphasis has also been placed upon the suicidal individual's conflict with his parents, which becomes heightened during the often stressful period of adolescence (Jacobziner, 1960; Toolan, 1962; Tuckman and Connon, 1962; Jacobs and Teicher, 1967). Clinical research into suicidal member families points to an inadequacy of training in long term problem solving techniques. Adolescents at risk are reported to display a marked rigidity in their life style and cognitive process, being unable to consider alternative solutions (Neuringer, 1964; Leonard, 1967). Regardless of success or failure they tend to disregard all external information, maintaining an unaltered level of aspiration (Vinoda, 1966). Having set rigidly defined goals they dichotomize concepts in their environment to the extreme, seldom allowing themselves many choices, thereby increasing the probability of self-destruction as an alternative when other solutions are blocked (Hendin, 1964).
This cognitive rigidity may in fact be linked to the general rigidity of family interaction which has consistently been reported in interactional studies of disturbed families. The rigidity and the concomitant absence of adaptive techniques are considered to precipitate progressive isolation from meaningful social relationships, often producing hasty, ill-considered escape activity (Jacobs, 1967; White, 1974).
Thus in view of the current evidence it is only possible to make a generalized statement to the effect that whether adolescent suicidal potential becomes activated will depend upon the environmental situation and pattern of social and interpersonal relationships especially those involving family members. Many aspects of the reported rigidity of interaction, role and communication disturbances should be amenable to direct empirical testing and Rosenbaum and Richman (1972) have recommended that such an undertaking be attempted.
Famlly Imteracticm Research The past two decades have witnessed an upsurge in the direct, experimental study of the family as an interactive unit in its own right. Initially investigators had hoped that a family typology and an integrated theory would be developed to explain the aetiology of specific psychiatric conditions in the individual. While this has not eventuated, there are recent indications that a family typology based on a behavioural description of the most prominent maladaptive behaviour of the identified patient may not be impossible (McPherson, et al., 1973). Although initial conceptual developments in interaction research were derived from studies of families containing a schizophrenic member, more recent research has attempted t o test the generality of concepts when applied to other types of families such as those containing neurotics, delinquents and retardates (OConnor and Stakowiak, 1971), under achievers (Leighton et al., 197 l), stutterers (Allan and Williams 1974), aggressive and submissive children (McPherson et al., 1973), as well as normal populations (Ferreira, 1963). Research has led to a growing body of evidence which suggests that there may be differential interaction patterns which distinguish type8 of disturbed from nondisturbed families. However there is still doubt as to the validity of some conclusions due in part to a lack of consensus on the appropriate methodology and on the definition of experimental variables. Another current issue relates to the nature of the relationship between interaction variables and the degree of psychopathology. While Ferreira and Winter (1965) suggest that the more extreme the disorder of a family member the more extreme the measures produced, Riskin and Faunce (1970) report that on many variables normal families tend to fall in the middle range, with the problem families at either extreme, depending upon the type of disturbance present.
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CHRISTOPHER WILLIAMSA N D CHRISTINA M. LYONS Comprehensive reviews of the diverse findings of interaction research are available elsewhere (Riskin and Faunce, 1972; Jacob, 1975). In general, studies t o date have focused on variables such as the efficiency of the family group functioning, its approach to decision making, the levels of conflict, cohesion, emotionality and adaptation in interaction and the differing power structures within family systems. Family decision making processes have been the subject of many well conducted experiments. Normal families tend to be more efficient and productive in their interactions, reaching a significantly greater number of family decisions than clinic families within the same time period (Murrell and Stachowiak, 1967; O'Connor and Stachowiak, 1971). Disturbed families are considered to display difficulty in operating at a group level, frequently failing t o resolve their differences, and exhibiting greater overt and verbalized rejection (Ferreira, 1963; OConnor and Stachowiak, 1971). Mutual reciprocity in communication is often lacking in families with a disturbed member and Haley (1959) contends that such a process is related to the formation of inter-member relationships. Haley (1962) and Schuham (1970) lend support t o this contention with the finding that families with a disturbed member reveal greater difficulty in formin& coalitions (particularly those between parents) than do normal groups. The latter tend to interact in a systems-integrating manner (Alexander, 1973) in which supportive processes between parents and their children are responded to in kind, whilst in abnormal interaction, more defensive prqcedures and hostility are emitted and reciprocated (Patterson et. al., 1972). Similar tendencies have been reported to occur in families containing a suicidal adolescent (Jacobs, 1967; Richman and Rosenbaum, 1970b). Differential power structures are a more contentious area of interaction research. Haley (1962) considers the normal family as egalitarian and the disturbed as authoritarian. In contrast Stabeneau et al., (19651, Murrell and Stachowiak (1967) and Schuham (1972) consider that normal families contain one member tending towards dominance. Wynne and Singer (1963) provide a reconciliation of these findings by postulating that it is the instability of role structure in disturbed families which impedes the child's opportunity to test a variety of roles during development. In relation to suicidal behaviour, disturbed role functioning has been noted in clinical studies of suicidal member families (Murphy, 1969; Richman and Rosenbaum, 1970a; Schrut, 1968). A number of variables related to intra-familial communication have been found to be sensitive indices of disturbed family functioning with the latter group displaying a greater number of ambiguous and general statements than controls (Lamson, 1969). A series of studies by Ferreira (1963), OConnor and Stachowiak (1971) and Stachowiak
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(1967), reveal a more open style of communication and greater agreement among normal family members as compared to disturbed families. Defensive messages, as observed in disturbed family functioning, are considered to impair symbolic functioning and sex role identification in the child (Becker et al., 1965). Suicidal member families are also considered to manifest these disturbed communication patterns in which adaptive channels are blocked (Jacobs and Teicher, 1967; Schrut, 1968). It has been reported that suicidal adolescents frequently exhibit communication patterns characterized by a chronic lack of involvement in interaction and an inability to express needs in a manner which leads to their gratification (Fawcett, et al., 1969). As a result family relationships are often confused or distorted and attempts at a meaningful exchange of ideas and a possible resolution of problems are ineffective (Jacobs, 1967; Richman and Rosenbaum, 1970b). Consequently the study of effectiveness of communication in families with a suicidal adolescent warrants further attention.
Learning Approaches In the light of the rapid development of the principles and procedures of behaviour modification, it is surprising that few systematic attempts have been made to integrate \data on suicidal behaviour into a learning theory. Frederick and Resnik (1971) note that it would be extremely difficult to explain self-destructive behaviours without employing learning principles. One of the earliest attempts to integrate data on suicidal behaviour and learning theory is represented by the simplistic drive reduction theory (Gr& and Mallin, 1967), where tension reduction contingent on the act is viewed as a reinforcing consequence which may effect the future repetition of the behaviour. A related interpretation of suicidal behaviour delineated by Lukianowicz (1972) and others, interprets the act as a learned avoidance response facilitating withdrawal from a temporarily intolerable situation. To date there is little empirical support for the widespread occurrence of this mechanism and the theory fails to adequately explain why this particular form of behaviour is originally chosen by the individual. A third learning hypothesis is that which considers the act to be acquired through vicarious imitation or modelling. The escalation of rates has been found to be greatest in areas already carrying high rates (Mills, et al., 1974), whilst other research reveals that up t o half the cases of adolescent suicidal behaviour have had direct contact with others exhibiting the behaviour, with a particularly high incidence in the family history. (Teicher and Jacobs, 1966; Rosenbaum and Richman, 1972). Thus experience of others exhibiting this pattern may lessen constraints against it. This modelling hypothesis does have explanatory strength in that it can account for the fact that the individual
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selects suicidal behaviour in the first place. It is further supported by the observation that suicidal behaviour may exhibit a contagion effect (Matthews, 1968). A final learning interpretation of aspects of suicidal behaviour is that based on the operant paradigm (Bostock and Williams, 1974, 1975). Studies emphasizing the consequent events of suicidal behaviour have given increased credence to the conceptualization of the behaviour as an attempt to modify or control the immediate environment (Rubenstein et al., 1958; Sifneos, 1966; Fawcett et al., 1969). It is considered that the consequent interpersonal interactions following suicidal behaviour, in some instances, reinforce and maintain the behaviour (Sale, et al., 1975). Even if the act is not originally designed to modify the environment, the contingent positive or negative consequences may still in fact reinforce the behaviour and contribute to its maintenance (Sifneos, 1966). The application of operant principles to the understanding and modification of maladaptive behaviour of children in family settings has been well documented (Patterson, et al., 1972). Often suicidal threats or gestures compel parents to acquiesce to their offspring, giving favoured treatment over other siblings (Lennard-Jones and Asher, 1959; Lukianowicz, 1972). Thus an investigation of reinforcement patterns in families may lead to fruitful explanatory and treatment implications.
METHOD The following predictions, based on the literature concerned with the interaction and communication patterns in disturbed families, are put forward for examination. As compared with the N group, the SM group interaction will evidence: (i) less effective productivity (total productivity being defined as the percentage of discrete effective and constructive speeches per total number of speeches), (ii) more conflict (total conflict being defined as the number of disagreements, interruptions and non-supportive simultaneous speeches), (iii) less adaptation (adaptation being defined as changes in member opinion in the direction of consensus), (iv) a significantly different pattern of role dominance (individual member role dominance being defined as the number of times a member speaks to and is addressed by others, plus the number of times an isolate decision is upheld), (v) less specificity (total specificity being defined as the number of speeches specifically addressed to a particular member). The following predictions are based o n behavioural theory which postulates that differential intrafamilial patterns of reinforcement may be related
to the development and maintenance of some classes of suicidal behaviour. (vi) There will be less supportive and more nonsupportive contingent speeches in SM family interaction as compared with N group interaction (supportive speeches being positive statements contingent upon a member’s response and expressing warmth, approval, interest and empathy: non-supportive speeches being negative statements contingent upon the previous response and indicating disapproval, disagreement or rejection of that response), (vii) there will be significant differences in the levels of positive and negative consequences emitted and received by each member of the SM family (positive consequences being agreement plus verbal and non-verbal expressions of approval, support or interest contingent upon the member’s speech: negative consequences being verbal or non-verbal behaviour indicating disagreement, disapproval, inattention and boredom contingent upon the member’s speech), (viii) there will be significant differences between the levels of positive and negative consequences received by each member of the SM family.
Subjects The sample consisted of a total of twelve family groups, six comprising the experimental group and six the control group. Each family had to consist of at least four members - mother, father, a female adolescent and one other sibling over the age of 8 years: with all four members having lived as an intact nuclear family for at least five uninterrupted years prior to the present study. No nonfamily member was to be present in the household. The suicidal member (SM) group consisted of families in which an adolescent female sibling, within the specified age range of 12-18 years inclusive, had presented for the first time at a general hospital following a drug overdose. Families meeting the general criteria were screened for evidence of psychiatric treatment for other family members and for evidence of psychosis in the suicidal adolescent. Neither the suicidal adolescent nor her family were to be engaged in on-going psychiatric treatment. The control or normal (N) group which consisted of families whose members had never received any form of psychiatric treatment, were individually matched with the SM group on the following variables which have been shown to bear a significant relationship t o interaction processes: nuclear family size, number of years of marriage, age of all members, sex and birth order of siblings, educational level, occupation and socio-economic status of the parents, and religion.
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CHRISTOPHER WILLIAMS AND CHRISTINA M. LYONS Procedure After initial contact, families were requested to attend a teaching hospital where a comfortable room was available for use. A remote control camera used for videotaping the interaction was placed inconspicuously in a far corner and was monitored from an adjacent, sound-proofed room. Procedural aspects and the time of day of observations were standardized. The SM group were videotaped between 3 and 4 weeks after the initial presentation. The method employed to elicit interaction was based on a modification of Strodtbeck's (1951) revealed differences technique. This method entails families being confronted with a hypothetical problem situation which they are requested to discuss in an attempt to decide on an alternative which best represents the thinking of the family as a whole. Eight items were selected for discussion from a questionnaire concerned with hypothetical problem situations related to family relationships. Prior to the discussion segments each family member privately responded to the questionnaire. Questionnaire items used to elicit discussion were those on which three of the four members agreed. Each family member had equal exposure as the isolate in the tetrad. In contrast to-the standard revealed differences method. the present procedure required that members neither be informed that their opinions differed nor be asked to reveal their individual attitudes. This unrevealed differences form is considered to produce a less contrived interaction. Six of the eight items were recorded, the first two items functioned as buffer items to allow the family to settle into interaction in as natural a vein as possible. This practice is undertaken as many researchers assume that after a short settling period, laboratory family interaction becomes more analogous to that observed in the naturalistic setting (Misher and Waxler, 1968). Rating codes were made as objective as possible in order to diminish error and two trained psychologists independently rated the interaction segments.
RESULTS Spearman Rank-Order correlation coefficients were computed between raters on the ranks of the various codes for each discussion. The resultant correlations ranged from 0.60 to 0.99, with a mean of 0.86. Results relating to the first group of hypotheses, those concerned with the efficiency and productiveness of family functioning, reveal a clear trend. The N families produced a significantly higher rate of effective speeches than the SM families (t = 7.046, d.f. = 5, p p >0.01). The third hypothesis was related to adaptation scores which were derived from the relationship between the number of pair differences in initial opinion and the number existing after family discussion. The N group had significantly higher scores than the SM group, indicating a higher level of eventual concensus despite initial differences (t = 17.101, d.f. = 5, p 0.05). Furthermore, no significant differences resulted when the dominance of individual members of the N family was compared with the respective member scores from the SM family group. While the percentage scores of total dominance for each member illustrated a hierarchical patterning in both groups of families, a number of descriptive trends are worthy of note. As compared with the N family group, role dominance was less evenly distributed between the SM group parents, and the SM sibling assumed greater relative dominance than her control sibling. The fifth hypothesis proposed that the interaction of SM families will be less specific than that of control families. While both groups gained high scores on this measure, the normal families specifically addressed a greater number of speeches to members (representing 75.96% of total productivity) than did SM families (69.07% of total speeches emitted being specific). The difference between the two groups on the specificity measure was statistically significant (t = 2.317, d.f. = 5, 0.05> p >0.025). The second group of hypotheses were concerned with the inference that differential patterns of reinforcement may be operating in the two groups of families. It was predicted that the SM group interaction would contain less supportive and more nonsupportive contingent speeches as compared with the N group interaction. The N group generated a significantly higher proportion of positive contingent statements (61.05%) as compared with the SM family group (21.39%). The difference was statistically significant ( t = 4.392, d.f. = 5, p p >0.005). A further hypothesis related to the proposed Operant component of interaction stated that each member of the SM group will emit and receive different rates of positive and negative consequences. Upon examination of the mean total proportion of reinforcement emitted and received by each member, several trends emerge. Both the SM and her sibling
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received a greater, though non-significant rate of positive consequences than they emitted (SM: t = 2.988, d.f. =3, p >0.05; Sibling: t = 2.188, d.f. = 3, p >0.05). The reverse pattern held for parents, both of whom dispensed more support than they received. This difference however, was not d.f. = 3, statistically significant (t = 2.775, p >0.05). For no member did the proportion of negative reinforcement emitted and received vary more than could be expected by chance. It was finally hypothesized that members of the SM family group would be differentiated by the rate of positive and negative consequences they receive. Kruskal-Wallis one-way analyses of variance were performed comparing each member. The rate of positive effect received per speech emitted did not differ significantly between members of the SM family group (H = 3.50, d.f. = 4, 4, 4, p >0.05). However the rate of negative consequences received per speech emitted did significantly discriminate between the three members (H = 5.69, d.f. = 4, 4, 4, p 0.001).
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DISCUSSION An examination of the overall results suggests that aspects of suicidal behaviour in adolescent females may bear a relationship to the social psychological properties of the nuclear family unit. Consonant with the specific predictions of interaction theory, the SM families displayed a significantly different pattern of functioning than that of N families: a pattern generally considered to be indicative of disturbance. This general conclusion lends confirmation to the findings of a wide range of clinical and epidemiological studies that implicate disturbances at the nuclear family level with some classes of suicidal behaviour (Tuckman and Connon, 1962; Haider, 1968; Rosenbaum and Richman 1970, 1972; Teicher, 1970; McCulloch and Philip, 1972; White, 1974). Interaction and Communication Patterns Related to the efficiency of the family group in its approach to decision making and the resolution of disagreements is the measure of effective productivity (Stachowiak, 1967). Whilst the N group interacted at a high level of effectiveness communicating many relevant statements, only approximately one third of the total productivity of SM families was coded as being efficient. A considerable proportion of their speeches were conflictual, uttered simultaneously, or unrelated to the discussion topic. Thus the SM families’ members were less able to communicate clearly and effectively in terms of content and interpersonal interaction. This finding is consistent with that related to other types of disturbed
families (Vandenberg and Stachowiak, 1966; MurrelI and Stachowiak, 1967). It is. considered that low effective productivity and minimd information sharing is indicative of rigid, disturbed family interaction (Riskin and Faunce, 1970). It is conceivable that the inability of some suicidal adolescents to emit and receive meaningful verbal communication (Graff and Mallin, 1967; Fawcett et al., 1969) may originate in such defective family functioning. Another measure related to the adjustment of family members is the level of conflict displayed in interaction (Murrell and Stachowiak, 1967). The significantly higher proportion of conflict in the SM family group resulted in discussions which were more fragmented and disorderly than those of N families with a relatively high rate of interruptions and simultaneous speeches. Similar patterns have been shown to characterize the interaction of disturbed families (Fisher et al., 1959; OConnor, 1967) and the findings are consistent with the clinical observations recording extreme dissension and disruption in interpersonal relationships in families containing a suicidal member (Teicher, 1970; McCulloch and Philip, 1967). It is of interest to note that on a descriptive level, the SM adolescent engaged in conflictual interaction with either or both of her parents, but displayed little conflict with her sibling. This tendency is consistent with that noted by Jacobziner (1960) and Tuckman and Connon (1962). Such disturbed parent-child relationships have frequently been cited as an important factor in families containing a suicidal member (Sabbath, 1969). The possible ramifications of such conflict for the suicidal adalescent are the deterioration of interpersonal relationships (Teicher, 1970; McCulloch and Philip, 1972) often leading to estrangement, progressive isolation (Sabbath, 1969; Jacobs, 1967) and an inability to cope effectively with problem situations. The interaction code of adaptation is hypothesized to be one of the factors involved in the development of intra unit structure which allows the family group to maintain itself as a consolidated system over time. Specifically the measure taps the ability of members to adjust and to cope with initial conflicts. The present finding that families with a disturbed member experience difficulty in reaching an efficient group decision has also been noted by Haley (1963) who suggests that the level of adaptation achieved by the family as a whole is related to the level of adjustment of the individual members. Realistic adaptation as displayed by N families is considered to be facilitated by the identification of specific view points, a mutual respect €or differences and constructive conflict resolution (Fisher, et al., 1959). The results indicate that as compared to N families, SM family interaction contained low rates of these behaviours. The resultant impaired problemsolving ability may also be related to the high level of conflict found in the interaction, as the SM families appeared to lack the ability to overcome dissension. White ( 1974) has attributed adolescent
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CHRISTOPHER WILLIAMS A N D CHRISTINA M. LYONS suicidal behaviour in part to the modelling of faulty problem-solving techniques designed to cope with stress.
In relation to the structural interactional variable of familial power relations or role dominance, the evidence is more ambiguous. The failure of disturbed families to adapt work together to overcome difficulties has been postulated to be due, in part, to an absence of parental influence, or a struggle for power (Murrell and Stachowiak, 1967). While a tendency towards ineffective leadership was noted in the dominance patterns of the SM family group, the measure failed to discriminate significantly between the two classes of families. As wide variability was noted for each class of families, it may be that this measure is not appropriate to tap the uniqueness of the integral structure of each family entity. Haley (1972) has reported that measures of process (conflict and specificity) and of outcome (productivity and adaptation) are generally superior to those such as role dominance which are related to family structure. The final interactional measure, that related to the specificity of communication, yielded significant results. Although a large proportion of family speeches in both groups were directed to individual members, specificity of address in the SM group was still significantly less than that of the N group. Thus they displayed a more general tendency in communication in a manner similar to that noted in other maladjusted families (O’Connor and Stachowiak, 1971; Stachowiak, 1967; Lamson, 1969). The relatively high rate of specificity may be related to the open hostility and conflict frequently reported to occur between SM family members. McPherson et al., (1973) reported a similar strong overtness and directness of communication in families with a behaviourally disturbed adolescent. Indices such as low productivity, specificity and adaptation. and high conflict, as noted in SM family functioning, are considered to be definitive of marked rigidity in interaction. This rigid adherance to stereotyped and ineffectual patterns of interaction has been reported to occur in a wide range of disturbed family groups and is considered by many theorists to be the hallmark of disturbed functioning (Haley, 1963). A considerable body of diverse research into suicidal behaviour does offer some support for this general contention. A marked rigidity in the life style and cognitive operations has been observed in several investigations (Neuringer, 1964; Leonard, 1967). It is considered that when faced with a problem the high risk individual tends to disregard external stimuli, adhering to rigidly defined goals and thus effectively blocking other solutions (Hendin, 1964; Vinoda, 1966). In the face of such a paucity of alternatives the suicide attempt may become a form of coping behaviour. A similar crisis intolerance (Richman and Rosenbaum, 1970a) or destructive and disintegrative
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reactions to stress situations have been found to characterize families with a disturbed member (Alexander, 1973). It may in fact be, as White (1 974) has postulated, that the rigid problem-solving behaviour of the suicidal individual is acquired through exposure to a similar rigid problem-solving pattern operating in the total family situation. Reinforcement Patterns The data do supply some preliminary support for the proposal that certain classes of suicidal acts may constitute a maladaptive behaviour pattern under the control of social stimuli and reinforcemenl (Frederick and Resnik, 1971; Bostock and Williams, 1974, 1975). The SM family evidenced fewer positive and greater negative contingent consequences than the control group. At an observational level SM families appeared less consistent in the type of contingent support given and this ten: dency coupled with the relatively low rate of positive contingent support may have mitigated against the facilitation of more adaptive behaviourr necessary for mutual co-operation. These findings may be interpreted in terms of the tendency noted in other maladjusted families by Patterson et al., (1972) and Alexander (1973). Elevated levels of negative support have been observed to produce in return more defensive, non-supportive communications, thus further increasing deviant-amplifying behaviours. The rates of positive and negative consequences dispensed in SM family interaction have further significance in the light of the proposition that supportive emotional messages are considered to play a vital role in the process of maintaining family solidarity, unity and cohesion (Vandenberg and Stachowiak, 1966; O’Connor and Stachowiak, 1971). It is conceptualized that such expressiveness is necessary to facilitate integrative relationships between members and to regulate tension levels. Thus it may be that the relatively low amount of positive consequences expressed by SM families was insufficient to promote a congenial cohesive atmosphere and reduce conflict. At any rate, other studies have confirmed the present observation of high rates of non-supportive or hostile affect in the interpersonal relationships of families containing adolescent suicide attempters (Vinoda, 1966; Richman and Rosenbaum, 1970a, 1970b; Connell, 1972). Few differences in the rate of consequences emitted to those received discriminated between SM family members at a significant level. This may have been due in part to the small sample of results available for this measure, but nevertheless certain trends did emerge. When data were n o m e d for participation effects, the SM received higher rates of both forms of consequences than did others. An analysis of family interaction by Patterson et al., (1972) reported similar rich reinforcement schedules dispensed to deviant boys. While the parental couple tended to send more positive support to their children than they received
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in turn, both the SM and her sibling were in receipt of a higher rate of positive consequences. The SM secured the highest rate of rewarding consequences relative to her output. Reid (1969) has reported that the more supportive consequences a disturbed child receives relative to the rate he emits per unit of interaction, the more he is likely to respond with coercive and deviant behaviour. Such a relationship between the deviation in reciprocity of positive rewards and the output of maladaptive behaviour may bear investigation in relation to some classes of adolescent suicidal behaviour. Although the SM was most efficient in gaining reward from interaction, she also received a significantly greater rate of negative consequences than her sibling, indicating that only the sibling was in receipt of consistent positive support for his or her behavioar. Such a differential pattern of reinforcement dispensed to each child may be related to the occurrence of behaviours related to attempted suicide. It has been suggested that this maladaptive response is used by the SM as a tactic for the securing of greater overall support and for modifying such relationships in her favour (Lukianowicz, 1972; White, 1974). While these contentions require further specific investigation, the relevance of the differential reinforcement pattern noted for the SM is underscored by reports that parents have been observed unintentionally to eliminate adaptive repertoires available to the suicidal adolescents (Jacobs, 1967).
CONCLUSION The findings of the present investigation suggest that the functioning of families containing a sibling who has engaged in self-poisoning differs significantly from that of normals. Specifically, it has been argued that impaired interaction, ineffective communication and inappropriate reinforcement contingencies may in fact be related to the genesis and maintenance of some classes of suicidal behaviour. However, considerable caution must be attached to the interpretation of these preliminary results. Methodological problems in family interaction research necessitated the use of a small, rigorously controlled sample and consequently generalization to the wider community of attempted suicides is not warranted. The further problem of the generalization from interaction samples to family behaviour in general has been outlined, and the final caution relates to the cross-sectional, retrospective nature of the study: a problem common to the bulk of research into suicidal behaviour. However it is argued that the direct, objective study of family interaction and adolescent suicidal behaviour will add valuable data to clinical and epidemiological studies. While the interpretation of each specific interaction measure is clearly most complex (Safilios-Rothschild, 1970), the methodology should allow adequate comparison across samples. Research findings to date suggest that on
certain measures family members engage in consistent patterns of interaction which remain comparatively stable over time and across situations (Ferreira and Winter, 1966; 'Murrell and Stachowiak, 1967). Furthermore, certain measures do differentiate families with a disturbed sibling from normal groups, and finally increasing evidence has demonstrated that therapeutic change can be brought about in one member when such measures are modified at the level of total family functioning (Alexander and Parsons, 1973; Patterson et al., 1972; Stuart, 1971). Consequently the systematic and objective study of family interaction should add to the understanding and management of adolescent suicidal behaviour.
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