How Change Happens: Controlling Images,Mutuality, and Power

SUMMARY

Change is inevitable but it can go in a positive direction toward growth or in a negative direction. Extending Patricia Hill Collins' concept of controlling images (2000), we can see how these images interact with relational images and strategies of disconnection to obstruct growth on both the societal and the personal level. In therapy, change is defined as movement-in-relationship toward better connection; and increased connection leads to growth. Several aspects of therapy that lead to deeper and wider connection are explored, especially increasing the patient's power. Prior versions of parts of this article were presented at the Jean Baker Miller Summer Training Institutes in 2001 and 2002 and at the 2002 Learning from Women Conference sponsored by the Jean Baker Miller Training Institute and the Harvard Medical School/Cambridge Hospital in Boston, Massachusetts.

As therapists, we're “in the business” of change–change for the better. That's our goal. Another word for change for the better is growth. Change is the essence of life. It is most obvious in children but it is a necessity through all of life. Change will occur inevitably but it can go in a positive or a negative direction. Further, I believe change toward growth creates pleasure. We feel most alive and zestful when we are engaged in this expanding activity.     

A Cross‐National Comparison of Suicide Attempts,Drug Use,and Depressed Mood Among Dominican Youth

We compared suicide attempts, depressed mood, and drug use of 1,710 Dominican public high school students in New York City (NYC) and 9,573 in the Dominican Republic (DR) in 2009. Compared to DR Dominicans, NYC Dominicans were more likely to have reported lifetime marijuana use (27.6% vs. 1.5%), lifetime inhalant use (11.0% vs. 7.6%), lifetime other drug use (9.9% vs. 3.0%), depressed mood (31.3% vs. 27.2%), and suicide attempt (13.8% vs. 8.8%). The results of this study supported the hypothesis that substantial increases in illicit drug use, especially cocaine, heroin, ecstasy, and methamphetamines, among NYC Dominican youth account for their increased risk for suicide attempts compared to their DR Dominican counterparts. It also identified suicide attempts as a public health problem among NYC Dominicans, the largest NYC Latino immigrant population.     

Postdeployment Suicide Risk Increases Over a 6‐month Period: Predictors of Increased Risk among Midwestern Army National Guard Soldiers

National Guard (NG) soldiers returning from deployments in Iraq and Afghanistan were surveyed at 6 and 12 months following their return (N = 970). The overall prevalence of suicide risk at 6 and 12 months following their return was assessed, as were changes in suicide risk among soldiers initially at high or low risk. Factors associated with changes in risk were assessed. The percentage of NG soldiers with high suicide risk increased from 6.8% at 6 months to 9.2% at 12 months (odds ratio = 1.7, p = .02). In the 882 soldiers initially at low risk, 5.9% (52/882) became high risk at 12 months; in the 64 soldiers initially at high risk, 46.9% (30/64) became low risk at 12 months. Initial levels of depressive symptoms were predictive of changing to high risk; this association appeared to be partially explained by soldier reports of increased search in the meaning in life and higher levels of perceived stress. Because suicide risk increases over the first 12 months, continued risk assessments during this time period should be considered. Supporting soldiers to find meaning in their life after deployment and enhancing their capacity to cope with perceived stress may help prevent increases in suicide risk over time.     

Have Mental Health Education Programs Influenced the Mental Health Literacy of Those with Major Depression and Suicidal Ideation? A Comparison between 1998 and 2008 in South Australia

Mental health literacy is the knowledge and beliefs about mental disorders that aid their recognition, management, or prevention and is considered to be an important determinant of help‐seeking. This has relevance in suicide prevention, as depression, the clinical condition most frequently associated with suicidality, has been the target of community and professional education programs designed to enhance mental health literacy. In this study, whether such programs have influenced help‐seeking attitudes and behavior in those who are depressed and suicidal was considered. The results indicate that despite intensive community education programs over the last two decades, there has been little change in those who are depressed and suicidal in terms of their attitudes toward treatment seeking and, more importantly, their treatment‐seeking behavior. These results draw into question the value of current community education programs for those most vulnerable to suicidal behavior.     

In Eating‐Disordered Inpatient Adolescents,Self‐Criticism Predicts Nonsuicidal Self‐Injury

We examined the role of depressive traits—self‐criticism and dependency—in nonsuicidal self‐injury (NSSI) and suicidal ideation among inpatient adolescents with eating disorders. In two studies (N = 103 and 55), inpatients were assessed for depressive traits, suicidal ideations, and NSSI. In Study 2, motivation for carrying out NSSI was also assessed. In both studies, depression predicted suicidal ideation and self‐criticism predicted NSSI. In Study 2, depression and suicidal ideation also predicted NSSI. The automatic positive motivation for NSSI was predicted by dependency and depressive symptoms, and by a two‐way interaction between self‐criticism and dependency. Consistent with the “self‐punishment model,” self‐criticism appears to constitute a dimension of vulnerability for NSSI.     

A Virtual Hope Box Smartphone App as an Accessory to Therapy: Proof‐of‐Concept in a Clinical Sample of Veterans

A “Hope Box” is a therapeutic tool employed by clinicians with patients who are having difficulty coping with negative thoughts and stress, including patients who may be at risk of suicide or nonsuicidal self‐harm. We conducted a proof‐of‐concept test of a “Virtual” Hope Box (VHB)—a smartphone app that delivers patient‐tailored coping tools. Compared with a conventional hope box integrated into VA behavioral health treatment, high‐risk patients and their clinicians used the VHB more regularly and found the VHB beneficial, useful, easy to set up, and said they were likely to use the VHB in the future and recommend the VHB to peers.     

What Factors Determine Disclosure of Suicide Ideation in Adults 60 and Older to a Treatment Provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least “a little bit” during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one‐unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence‐based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences.     

National Suicide Rates a Century after Durkheim: Do We Know Enough to Estimate Error?

Durkheim's nineteenth‐century analysis of national suicide rates dismissed prior concerns about mortality data fidelity. Over the intervening century, however, evidence documenting various types of error in suicide data has only mounted, and surprising levels of such error continue to be routinely uncovered. Yet the annual suicide rate remains the most widely used population‐level suicide metric today. After reviewing the unique sources of bias incurred during stages of suicide data collection and concatenation, we propose a model designed to uniformly estimate error in future studies. A standardized method of error estimation uniformly applied to mortality data could produce data capable of promoting high quality analyses of cross‐national research questions.