Today’s workshop,  Bullying, Depression and Suicide Among Adolescents, was presented by Anat Brunstein-Klomek, Ph.D. , a Clinical Psychologist, Senior Lecturer at the School of Psychology at the Interdisciplinary Center (IDC), Herzlyia, Israel, and Adjunct Assistant Professor of Clinical Psychology in the Division of Child and Adolescent Psychiatry at Columbia University. Her presentation covered both theory and practice in treatment of these disorders.

Dr. Brunstein- Klomek’s style was calm and soft-spoken, the quiet competence of the expert. Her presentation was clear and straight-forward, making these complex topics seem very understandable.  Although she presented a good deal of data in the first half of the presentation, Dr. Brunstein- Klomek bought the data to life with anecdotes from her clinical practice.

All three workshop objectives were met. These were:

1.  Understand the definition, types and epidemiology of bullying behavior and suicidal behavior among adolescents.

Dr. Brunstein- Klomek provided a concise definition of peer bullying that included three elements: Aggression, power imbalance, and chronic/ongoing incidents. She talked about 4 types of bullying: 1. Physical, 2. Verbal, 3. Relational, and 4. Damage to Property. Dr. Brunstein- Klomek also mentioned that cyberbullying is not conceptually different from traditional bullying.  On the other hand, the unique characteristics of cyberbullying include the anonymity of the bully, lack of opportunities of empathy for the victim, and lack of awareness of the bully of the consequences.

According to recent research, there are 4 types of adolescents involved in bullying behavior: Bullies, Victims, Bully-Victims, and Bystanders. The Bully-Victims are kids who are both Bullies (school?) and Victims (community?). Bystanders include all other witnesses to bullying, including adults, who are passive participants with an opportunity to intervene or provide support to the victim.

Points stressed in today’s workshop (take-home messages) included:

• Bullying is not a normal part of development, as previously thought.
• Although the media focuses on the impact of bullying on the victim, Dr. Brunstein- Klomek made it clear that both bullies and victims are at risk for serious mental health problems, including suicidal behavior in the future.
• The media focus may continue the belief that suicide is a natural consequence to being bullied.

2.  Become familiar with the research examining the association between bullying and suicide among adolescents, including cross-sectional and longitudinal research findings.

As sometimes occurs with the “theory/research” part of a workshop, Dr. Brunstein- Klomek’s presentation did not take me back to the graduate school classroom lectures.  It was fun listening to the data, and her stories about the research projects and the kids involved. The time went by quickly.

To summarize her overview of the research, children and adolescents are at higher risk for psychopathology and suicidal behavior later in life, if there is co-morbid depression or other serious mental illness when being bullied.

Two types of recent and current research were presented. Cross-sectional research (a single period of time) looked at bullying in and out of school, bullying behavior with depression, suicidal ideation and suicide attempts by gender, and impact of the co-occurrence of bully-victims. Outcomes suggest that bullying (bullies or victims) is associated with depression, suicidal ideation and attempts. Bully-victims are at the highest risk for depression, suicidal ideation and suicide attempts.

Gender differences are associated with the frequency of involvement in bullying. Females are more likely to suffer adverse consequences with any bullying. Males who are involved in frequent bullying, are associated with more adverse outcomes.

Dr. Brunstein- Klomek said that cross sectional studies are sometimes difficult to interpret. Although the results show association among variables such as depression, bullying and suicidal behavior, they do not show causality.  She presented several longitudinal studies, which track patients over a long period of time. These studies looked at the same patients during childhood, adolescents and as adults. Conclusions from the longitudinal research include:

• There is a complex relationship between bullying and risk of suicidal ideation/behavior.
• Both bullying and victimization puts adolescents at risk of suicidal ideation, especially when other psychopathology is present.
• We don’t know if bullying directly causes suicide-related behavior. It is a risk factor.
• Bullies, victims, and bully victims are different groups. Bully-victims are at high risk.
• Genders have different risk profiles.
• More need for support of both victims and bullies.

3. Learn therapeutic interventions, which target risk for depression, suicide and bullying among adolescents.

The second half of today’s workshop focused on treatments for adolescent suicide prevention. Overviews of two methodologies were presented. Dr. Brunstein- Klomek said that Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) and Interpersonal Psychotherapy (IPT) have somewhat different theoretical backgrounds. She has found that the two techniques can also be effective when elements are combined for suicide prevention with adolescents. Dr. Brunstein- Klomek stressed that her workshop is only designed to present an overview of these techniques to whet the appetite for further learning, not to teach these techniques.

CBT-SP is a combination of cognitive-behavioral techniques based on Beck’s model. This includes skills enhancement based on Dialectic-Behavior-Therapy, and Family Therapy. Typically, there are three phases, the first and second phase are typically completed in 12 weekly sessions. The early sessions focus on development of the safety plan which is core to the success of the program. Detailed elements of the safety-plan were presented. Dr. Brunstein- Klomek also discussed the use of the “Chain Analysis,” which is also essential to the CBT-SP program. Both of these elements are dynamic, and expected to be revisited and possibly changed at each session.

The final “Relapse Prevention” phase of CBT-SP encourages the patient to re-live the emotions of the suicidal thoughts, and practice the coping skills taught during treatment.  All elements of the CBT model, including psycho-education, cognitive restructuring, behavioral activation, and emotional regulation are incorporated during this treatment. Family involvement is expected at each session.

Interpersonal Psychotherapy (IPT) is derived from Attachment Theory, Interpersonal Theory and Social Theory. The core principles state that depression and social relationships are interconnected. A change in one can cause a change in the other, possibly leading to suicidal ideation. Although derived from a different theoretical background than CBT, it also is conducted in three phases. The first phase emphasizes a safety plan, psycho-education, a Problem Area Formulation and a treatment contract.  The middle phase includes an interpersonal “Communication Analysis,” which focuses on the detail of the interpersonal communication between and among the people identified as significant relationships by the patient. The termination phase monitors depression symptoms and suicide risk and teaches application of skills learned to future situations. As in CBT-SP, the final phase reviews the safety plan. All sessions include family members during treatment.

Throughout the workshop, the audience was quiet and respectful. For the most part, questions were relevant to the discussion and answered well by Dr. Brunstein- Klomek. As usual, a few questions were too long, and misplaced. For example, although she was clear that the workshop was in two parts, first theory/research and second clinical practice. A couple of folks tried to speed up the lecture by asking clinical practice questions during part one. Dr. Brunstein- Klomek did not break stride in her polite and patient response to these questions. Also some questions were difficult to hear. It’s always better if the person with the microphone repeats the questions.

Aside from a complaint about temperature in the upper part of the auditorium, response from people around me was very positive. Most everyone stayed to the end of the presentation. I did not notice the fidgeting and paper noises that sometimes occur toward the end of a workshop. I appreciated the research update, and I learned a few things. Overall, I thought this was a very satisfying workshop.

What did you think?