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Continuity and commitment in adolescence : a cognitive-developmental study of suicidal and nonsuicidal… Ball, Lorraine Vivien 1988

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CONTINUITY A N D C O M M I T M E N T IN A D O L E S C E N C E : A C O G N I T I V E - D E V E L O P M E N T A L S T U D Y O F SU IC IDAL A N D NONSUIC IDAL Y O U T H by LORRAINE VTVIEN BALL B.A. (Psychology & E.C.E), University of Waterloo, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF, THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS, DEVELOPMENTAL PSYCHOLOGY. in THE FACULTY OF GRADUATE STUDIES Department of Psychology We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA February 1988 © LORRAINE VIVIEN BALL, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Psychology The University of British Columbia 2075 Wesbrook Place Vancouver, B.C. Canada February 1988 ABSTRACT This research was conducted in the hope of making some contribution to the emerging field of developmental psychopathology through an examination of the relations between progressive movement toward social-cognitive maturity and socioemotional adjustment in adolescence. The two developmental matters of particular concern were the contrastive ways in which suicidal and nonsuicidal adolescents undertake to secure a sense of their own personal continuity across time, and a sense of conviction in the face of growing skeptical doubts. Alternative accounts of suicidal behaviour generally fail to offer any explanatory framework with which to account for the sudden and dramatic increase in suicidal behaviour during the adolescent years. It is argued in this thesis that the self-destructive tendencies of suicidal youth may be better understood as behavioural manifestations of difficulties in dealing with the developmental matters of personal continuity and nascent skeptical doubt More specifically, the arguments presented in this thesis lead to the hypotheses that suicidal adolescents are less able than their nonsuicidal age-mates to 1) adequately warrant their own and others' persistent identity across time, and 2) make use of more mature strategies for dealing with issues of uncertainty and doubt. To test these predictions, 29 psychiatrically hospitalized suicidal adolescents, who were subsequently categorized in to either a high suicide risk group (n=13) or a low suicide risk group (n_=16), and an age- and sex-matched group of 29 high school students were individually administered: (1) The Continuity Measure, comprised of 2 stories and a semi-structured interview procedure which inquires into how subjects warrant their own and others' personal continuity in the face of dramatic personal change; (2) The Nascent Skeptical Doubt Interview, also comprised of 2 stories and an associated semi-structured interview procedure aimed at determining subjects' characteristic strategies for dealing with uncertainty; and (3) The Nascent Skeptical Doubt Questionnaire, which permits the placement of respondents along an objectivist-relativist dimension. The results of this study indicate that, in comparison to their nonhospitalized age-mates, the psychiatrically hospitalized suicidal adolescents did evidence difficulties both in their abilities to understand how they and others could be said to remain continuous or self-same persons throughout time, and in their ability to cope with questions of uncertainty and doubt. In addition, adolescents at high risk for suicide were distinguished from other psychiatrically hospitalized individuals at low risk to suicide, and from their high school age-mates by: 1) their unique inability to find any workable means of justifying persistent identity across change; and 2) by their more extreme endorsement of absolutistic views in the face of uncertainty. These findings are seen to lend support to the general theoretical attempt of this thesis to interpret certain socioemotional difficulties experienced by adolescents as arising from a developmental asynchrony between progressive movement toward the more abstract, relativized, and self-reflective modes of thought associated with cognitive maturity, and the task of securing more mature strategies for dealing with the reconceptualizations of the problems of continuity and doubt which these cognitive advances necessitate. In addition, a number of theoretical, diagnostic, and treatment implications which are seen to follow from the results of this study are discussed. TABLE OF CONTENTS Abstract ^ Table of Contents i v List of Tables .vfe. Acknowledgement y^K Chapter 1: Introduction . 1 Statement of the Problem 1 A Synopsis of Competing Accounts of Suicidal Behaviour 6 Social-Cognitive Developmental Interpretations of Suicidal Behaviour ..13 Identity Diffusion and Adolescent Suicidal Behaviour 14 Skeptical Doubt and Suicidal Behaviour in Adolescence 22 Summary of Hypotheses 28 Chapter 2: Method 31 Measures 31 Procedural Summary , 37 Subjects 37 Materials 39 Procedure 41 Scoring 42 Chapter 3: Results 46 The Normative Sample as an Appropriate Comparison Group 46 Continuity and Suicidal Risk 50 Nascent Skeptical Doubt and Suicidal Risk 56 The Nascent Skeptical Doubt Interview 56 The Nascent Skeptical Doubt Questionnaire 61 Summary of Results 64 Chapter 4: Discussion 70 Details and Implications of the Research Findings 71 Theoretical Implications 71 Diagnostic and Treatment Implications 75 Limitations and Suggestions for Future Research 77 References 80 Appendices 88 A. Numerical Identity Interview Procedure 89 B. Nascent Skeptical Doubt Stories and Interview Procedure 92 C. Nascent Skeptical Doubt Questionnaire 96 D. Suicidal Risk Rating Scale 100 v i LIST OF TABLES TABLE 1: A Typology of Possible Continuity Warrants 17 TABLE 2: Strategies for Dealing with Nascent Skeptical Doubt 24 TABLE 3: Discharge Diagnosis by Suicidal Risk 45 TABLE 4: Type of Continuity Warrant by Age 47 TABLE 5: Responses to Nascent Skeptical Doubt 49 TABLE 6: Response to Nascent Skeptical Doubt by Age 51 TABLE 7: Type of Continuity Warrant by Suicidal Status 53 TABLE 8: Type of Continuity Warrant by Suicidal Status, Self Only 57 TABLE 9: Responses to Nascent Skeptical Doubt by Suicidal Status 59 TABLE 10: Responses to Nascent Skeptical Doubt, Suicidal vs. Nonsuicidal 60 TABLE 11: Scores on the Doubt Questionnaire by Doubt Interview Responses 63 TABLE 12: Scores on the Doubt Questionnaire by Suicidal Status 65 TABLE 13: Discriminant Function Analyses, Classifying Suicidal Risk 68 ACKNOWLEDGEMENTS On this page I would like to thank the many people whose help directly contributed to the successful completion of this project, and the many others who, intellectually and emotionally, have guided and supported me throughout this project. To my supervisor, Michael Chandler, I would like to express my deepest gratitude for the ever thoughtful intellectual guidance he has generously and unfailingly provided throughout the hundreds of hours he has dedicated to this project and to my education. I would like to thank Larry Walker and Keith Dobson for serving on my thesis committee and for their helpful comments and unqualified support of this research project. I wish to acknowledge the contributions made by Michael Boyes, Suzanne Hala, and Mita Banerjee as members of our research group out of which emerged the conceptualization and materialization of the central measures employed in this study, and for their efforts in collecting the normative data for this study. I wish also to extend my appreciation to the Psychology Department of the Vancouver General Hospital, with special thanks to Merv Gilbert and Dan Bilsker, and to the staff, parents, and adolescents associated with the Adolescent Psychiatric Unit without whose co-operation and participation this project could not have been completed. Finally, for all those less easily definable ways in which I have been helped and influenced throughout the tenure of this project, I wish to thank Anne Fritz, Eric Ball, Jonathan Druhan, Warren Weir, Judith Cutshall, and Joshua Druhan. 1 C H A P T E R It INTRODUCTION STATEMENT OF THE PROBLEM This research was conducted in the hope of making some contribution to the emerging field of developmental psychopathology, and with the specific aim of promoting a better understanding of the phenomenon of adolescent suicidal behaviour. The strategy adopted to accomplish these purposes was to attempt to locate some responsibility for the self-destructive acts of a group of suicidal adolescents within the interpretive context of normative social-cognitive developmental theory. The range of cognitive accomplishments typically associated with adolescent development are generally recognized to promote a variety of positive and prosocial consequences, including a growing awareness of, and sensitivity to, the thoughts and feelings of others (see Chandler & Boyes, 1982; Shantz, 1983, for recent reviews). There is, however, a darker and less well understood side to these otherwise positive achievements and the focus of this study was upon two of these consequences (Chandler & Ball, in press). In the first instance, attention was directed to the manner in which the cognitive achievements of the adolescent period sometimes disrupt the normal process of identity formation. Here, the focus of concern was on the ways in which certain failures in the process by means of which young persons attempt to secure a sense of continuous or numerical identity across time may serve to precipitate crises of identity. Secondly, attention was directed to the ways in which these same cognitive changes sometimes promote a potentially destabilizing sense of uncertainty and skeptical doubt that can undermine the efforts of adolescents to act with conviction and commitment. The scope of work outlined above is best viewed as being of a conceptual piece with that of other investigators (Achenbach, 1974; Cicchetti, 1984; Garber, 1984; Selman, 1976, 1980) who also have focused attention upon the ways in which disruptions in the usual cognitive-developmental course may promote a variety of maladaptive behaviours. To date, however, the bulk of this related research has been concerned with the emergence of such difficulties in the preschool and middle-childhood years. Consequently, much less is known about the relations between the course of social-cognitive development and the socioemotional difficulties experienced by adolescents. The central task of this thesis, then, was to partially redress this short-fall by examining the relation between progressive movement toward cognitive maturity and socioemotional adjustment in the adolescent period. This was accomplished through a comparative analysis of the manner in which both normal adolescents and other emotionally troubled youth warrant their own continuous or numerical identity across time, and respond to their growing sense of uncertainty and skeptical doubt. The particular patient population of greatest interest in this study was that of young persons who have expressed their adaptational failures by making attempts on their own lives. The rationale for choosing this particular study population is taken up in the sections that follow. Adolescent Suicide and the Problem of Numerical Identity A long history of philosophical and psychological thought has contributed to the view that an essential component of any mature sense of identity is the ability to count oneself as a singular or numerically identical individual despite the inevitability of personal change (Erikson, 1968; Lifton, 1976; Maclntyre, 1981). In an earlier effort, I and my research colleagues (Chandler, Boyes, Ball, & Hala, 1986) undertook to document how normal adolescents commonly justify or warrant their own sense of continuous identity. In this earlier study, typical adolescents were found to employ one or another of a series of increasingly adequate strategies for solving the problem of their own and others' numerical identity. Based upon evidence from this earlier normative study, which demonstrated that the intellectual achievements of adolescents often cost such young persons confidence in their own earlier continuity warranting practices, it was hypothesized that such cognitive changes might sometimes place young persons in the destabilizing position of having outgrown their previous means of understanding their own personal continuity before having as yet acquired more adequate methods of resolving this problem. Without some effective means of welding links between their own past and likely future, such adolescents, it was argued, might temporarily lose their sense of personal continuity and consequently any coherent sense of selfhood. Such young persons, it was reasoned, would be especially vulnerable to various crises of identity and, because of their lack of commitment to and connectedness with- their own futures, would be at risk to suicide. Adoleserit Suicide and the Emergence of Skeptical Doubt Over and above the risks to suicide precipitated by the continuity problems outlined above, it was also assumed that adolescents are sometimes the victims of a second developmental asynchrony created by their inability to accomodate the doubts and uncertainties that naturally accompany their increasingly relativized conception of knowledge. Again, previous research (Boyes, 1987) has indicated that the growing recognition of the subjective character of the knowing process, common to most adolescents, sometimes makes untenable their own previous means of securing a sense of absolute certainty without simultaneously providing for some better means for proceeding in the face of such ambiguities. Lacking any workable strategy for achieving personal conviction in an uncertain world, such adolescents may find themselves unable to ground their own beliefs or to justify the making of personal commitments. Such crises of confidence, it was hypothesized, might also promote a variety of extravagent and even self-destructive behaviours. The Target Population: Why Study Suicidal Youth? The preceding arguments are intended to introduce the possibility that the routine cognitive accomplishments of the adolescent period naturally carry in their wake certain adaptational problems. In particular, it has been suggested that adolescents are commonly forced to contend with a new sense of uncertainty or skeptical doubt, and are newly confronted with the difficult task of warranting their own personal continuity or numerical identity. While limited evidence is currently available to suggest that these adaptational problems account for some of the difficulties experienced by normal adolescents (Boyes, 1987; Chandler, Boyes, Ball, & Hala, 1986), a deeper understanding of this relationship was seen to require the study of young persons who occupy a broader range of adolescent adjustment problems. Consequently, the comparative study of extreme groups of young persons who differ dramatically in the success with which they have come to terms with the demands of adolescent development constituted a natural extension of this earlier work. While any one of a variety of contrast groups might have been chosen for this purpose, the present study undertook to explore the differences which divide "normal" adolescents from those who have attempted to end their own lives through various suicidal actions. Justification for this choice lies in the fact that, in contrast to adolescents more generally, suicidal youth appear to constitute a kind of end-state group of young persons who, through their own self-destructive acts, have defined themselves as being in an all but terminal state of developmental crisis. Consequently, for the purpose of this study, the making of serious suicide threats and attempts was taken as an operational definition of dramatic adaptational failure, and adolescents who qualified for this dubious distinction were contrasted with adolescents more generally. The present attempt to interpret the suicidal acts of certain adolescents as extreme reactions to social-cognitive problems common to young persons more generally is sufficiently novel as to require elaborate justification. Consequently, in what follows, three tasks will be taken up in turn. First, the scope of the problem of adolescent suicidal behaviour will be outlined. Second, a summary of competing accounts of suicidal behaviour will be offered as a preamble to a more elaborated discussion of the alternative explanation of this phenomena to be attempted within the context of this research. Finally, a summary and particularization of the hypotheses of this study will be detailed. Suicidal Behaviour in Adolescence: How Serious a Problem? It is a well documented but poorly understood fact that actual suicides and suicide attempts, both of which are extremely rare in younger-children, suddenly and dramatically increase in frequency during the adolescent years (Carlson, 1983; Diekstra & Moritz, 1987; Hawton, 1986; Shneidman, 1985). Reported suicides in Canada for the 15- to 19-year-old age group jump from previous rates of less than .5 per 100,000 for younger children to approximately 12.1 per 100,000 for those in their teenage years (Statistics Canada, 1981). Even more dramatic are the estimated rates of adolescent suicide attempts, of which there are from 50 to 150 for every completed suicide (McKenry & Kelly, 1983). This ratio of attempted to completed suicides is dramatically different from the counterpart ratio of 10:1 for adults estimated by Jacobziner (1965) and Carlson (1983). 1 Related findings (Ross, 1985), based on self-report 1 Although reported sex ratios differ by age group, location, and year, the recent trend, both within Canada and internationlly, has been for males to outnumber females by approximately 1.7:1 to 2.7:1 in actual suicides (Madison, 1978; Shneidman, 1985; Syer, 1981), while females tend to outnumber males in number of suicide attempts, at least in the under measures, indicate that 10% - 13% of high school students and 15% of college students reported having made one or more suicide attempt. The seriousness of such figures is underscored by the fact that, across all age groups, between 20% - 65% of actual suicides are completed by persons who have made previous attempts, and that 10% - 15% of attempters eventually kill themselves (Carlson, 1983; Hendin, 1982; Kreitman, 1981), often within 2 years of their first attempt (Dalgren, 1977). Incidence figures of this sort need to be viewed with caution. Self-report measures may spuriously inflate the number of estimated suicide attempts and more "objective" measures almost certainly under-report (Nelson, Farberow, & MacKinnon, 1978; Taylor, 1982). On the assumption that the "truth" falls somewhere between these extremes, however, available evidence makes it clear that suicidal behaviour, which is almost nonexistant in the childhood years, becomes a serious problem in adolescence. Why this should be so -why the sudden increase in suicidal behaviour in the adolescent years - is among the questions that prompted the present study. A SYNOPSIS OF COMPETING ACCOUNTS OF SUICIDAL BEHAVIOUR Despite extensive documentation of the problem of adolescent suicidal behaviour, there has been a serious shortage of methodologically sound studies on this topic. In their review of the 40 empirical reports appearing in the English language literature between 1960 and 1979, for example, Berman and Cohen-Sandier (1982) found that only 10 of these had employed any control or comparison group whatsoever, just 4 had operationally defined the suicidal sample, and only 9 had subjected their results to statistical analyses. Methodological problems aside, the great 1 (cont'd) 30 age group. Across sixteen studies in which such comparative data are available, the number of female to male attempts ranged from equal numbers of both sexes to four female for every one male who attempted suicide with a mean ratio of approximately two (1.8) to one (Termansen, 1972; Wexler, Weissman & Kasl, 1978). majority of empirical studies to date have focused on age independent issues of demography, precipitating events, family characteristics and behavioural correlates, none of which have much to contribute toward an understanding of the apparent association between becoming adolescent and increased vulnerability to suicidal behaviour. Not only is it the case that the body of recent empirical research on adolescent suicidal behaviour is extremely sparse, but similarly, most existing theoretical accounts fail to offer any explanatory framework with which to account for the dramatic increase in suicidal behaviour during the adolescent years. In fact, most explanations of suicidal behaviour make few, if any, distinctions regarding the age or developmental station of those who make attempts upon their own lives. The extent of this omission is made clear by the following review which summarizes the main thrust of sociological, psychodynamic, and cognitive accounts of suicidal behaviour. Sociological Accounts of Suicidal Behaviour As is widely known, Durkheim (1897/1966) is credited with having done early ground-breaking work on suicide within the field of sociology. From Durkheim's perspective the frequency of suicide within any given social group is understood to be the consequence of the degree to which that society has failed to meet certain basic human needs. Individual well being, according to Durkheim, requires a certain optimal balance between social and personal identity on the one hand, and social constraint and individual independence on the other. The direction in which this balance of needs and presses is tipped within any given society was understood by him to determine which of four types of suicide individuals are likely to commit. These four types of suicide are referred to as 1) egoistic, 2) altruistic, 3) anomic, and 4) fatalistic. In terms of the social structure of society, two dimensions are identified: a social integration dimension and a vulnerability to deregulation dimension (Krauss, 1976). What Durkheim called "egoistic suicide" is associated with a lack of social integration, most typical in societies with low social cohesion. This lack of integration of religious, domestic, or political society is said to weaken the collective force of social bonds which serve to restrain individuals from suicide by directing them away from self-oriented reflection and the subsequent feelings of isolation and meaninglessness. By contrast, Durkheim's second or "altruistic" type of suicide is said to occur in overly integrated societies where personal identity is highly subordinated to social identity. In such a setting, the life of a specific individual is accorded little meaning or value beyond its social contribution. Suicide within this type of social structure is said to stem either from a failure to live up to the expectations associated with one's social role, or from so complete an identification with some extra-personal goal that one's life may be sacrificed in its pursuit. What Durkheim described as "anomic suicides" find their explanation along his second dimension of deregulation. Such self destructive acts are associated with conditions in which normally functioning social controls are loosened. This loss of social restraint and control, according to Durkheim, leaves individuals without the kind of guidance necessary to identify and pursue goals, and thus without "resistance" to suicide. The other end of this dimension defines the social conditions under which "fatalistic suicide" is said to most likely occur in response to excessively oppressive social regulation. Durkheim's explanatory model, like that of other more contemporary investigators working within this sociological tradition, was primarily intended as a means of accounting for differential suicide rates in different cultures and, as such, is only indirectly concerned with matters of individual difference. While his theory does assume certain core psychological dynamics (i.e., both a tendency toward self-reflection, which is associated in the extreme with skeptical uncertainty, and a need to seek out some extra-personal imperative associated with systems of organized faith), these factors are subordinated in his view to what are for him more compelling matters having to do with different social structures. In support of Durkheim's theory, suicide and attempted suicide rates do seem to fluctuate over time and differ by country and culture (Biller, 1977; Boss, 1976; Carlson, 1983; Hendin, 1982; Madison, 1978). Any more adequate psychological understanding of such suicidal behaviour must, however, attempt to shed some light upon what it is about particular individuals within a given social structure that leads some, but not others, to undertake to end their own lives. Psychodynamic Accounts of Suicide Psychodynamic theories represent a second major tradition in the study of suicidal behaviour, and one that does emphasize the affective roots and individual pathological nature of such acts. Freud, for example, offered two such interpretations of suicide: (1) the narcissism-frustrated theory and (2) the death instinct hypothesis. The latter interpretation, which has garnered little support, basically proposes that suicide represents the precocious victory of the inner drive toward death (Krauss, 1976). As Hendin (1982) points out, however, such an interpretation has little explanatory power in that it amounts to little more than a roundabout way of saying that people kill themselves. The more popular narcissism-frustrated theory suggests that narcissistic attachments to libidinal objects result in highly unstable object relations because of their excessive demands for gratification. Given the narcissistic identification with such objects, the frustration and anger created by their eventual loss may, according to Freud, become directed at the self. In the extreme, such self-directed rage may lead to suicide (Krauss, 1976). This theoretical interpretation, while difficult to test directly (Bennum, 1984), underlies a number of psychodynamically inspired accounts that focus on early family dynamics (Brown, 1985; Madison, 1978) or various emotional losses as precipitating factors in suicide (Farberow, 1985; Peck, 1985). As with psychodynamic interpretations more generally, however, such accounts often amount to case specific explanations that narratively incorporate individual personality and situational variables but lack generalizability. Attempts to remedy the idiosyncratic nature of such interpretations of suicidal behaviour have tended to take one of two forms. On the one hand, there are a number of investigators who, while still theory driven, have adopted an eclectic approach often involving some mixture of both psychodynamic and sociological theories (i.e., see Hendin, 1982; Krauss, 1976; Madison, 1978). While any behavioural act, including suicide, is almost certainly multi-determined, such eclectic approaches often tend toward conceptual incoherance as the locus of responsibility for the self destructive act shifts more or less haphazardly with the individual case. On the other hand there are those researchers who appear to have abandoned all theories and have opted for more data driven approaches to the problem of suicide (Arffa, 1983). Representatives of this unguided empirical orientation tend to lean upon other theoretically and empirically driven studies and have typically proceeded opportunistically to identify interrelations between a mosaic of borrowed variables (e.g., see McKenry & Kelly, 1983; Siegel & Griffin, 1983). Research of this sort gains a certain amount of generalizability but ultimately suffers from the lack of a conceptual framework within which to place these results or make them comprehensible. Common to all of these, as well as to the previously mentioned approaches, is that little distinction is made between the suicidal behaviours of various age groups. The sudden increase in such behaviour in adolescence, when it is noted at all, is generally attributed in some post-hoc fashion to the biological and social changes which are assumed to characterize this period. Cognitive Accounts of Suicidal Behaviour Finally, a number of researchers have focused attention upon the relation between cognition and suicidal behaviour. However, with few exceptions, these cognitively oriented investigators have also favoured a kind of "narrow empiricism" (Taylor, 1982) which largely avoids any theoretical analysis and leaves untouched the particular issues unique to the suicidal acts of adolescents. One major emphasis within this cognitive approach has been the characterization of aspects of cognitive style associated with suicidal behaviour. The most consistent findings here are that suicidal individuals tend to display rigid, dichotomous thinking (Arffa, 1983; Beck, Rush, Shaw, & Emery, 1984; Faberow, 1985; Neuringer, 1961, 1964, 1967; Neuringer & Lettieri, 1982; Patsiokas, Clum, & Luscomb, 1979), poor problem solving abilities (Arffa, 1983; Berman & Carroll, 1984), low tolerance for uncertainty (Beck et al., 1984; Taylor, 1978, 1982), restricted time perspective (Beck et al., 1984; Berman & Carroll, 1984; Taylor, 1978), and fear of loss of control (Arffa, 1983; Hendin, 1982; Shneidman, 1985). More comprehensive investigations into the contributions of cognitive style to suicidal behaviour have been undertaken by suicidologists such as Shneidman (1985) and Faberow (1985), and by researchers in the newly emerging cognitive-behavioural orientation. Shneidman (1985) argues that the psychological circumstances associated with suicide are most "accurately seen as a more or less transient psychological constriction of affect and intellect" (p. 138) which is manifested in a reliance upon dichotomous thinking such that the problem solving alternatives reduce to either the finding of "some specific (almost magical) solution or cessation". Associated with this constricted cognitive state are those idiosyncratic and destructive styles of reasoning Shneidman refers to as "catalogical reasoning". In an attempt to elucidate specific aspects of this suicidal mode of thought, Shneidman developed a system of logical content analysis based on principles of formal logic which he applied to suicide notes. The types of logical fallacies most commonly identified in such notes were: 1) semantic fallacies which are dependent on the ambiguous meaning of terms; and 2) psychosemantic fallacies which involve fallacious identification in which one imagines oneself as a spectator-survivor to one's own death (Shneidman & Faberow, 1957; Shneidman, 1985). According to this view, while suicidal behaviour is generally assumed to be a multi-faceted phenomenon, it is the suicidal logic which ultimately leads to the lethal decision to take one's own life. Parallels between Shneidman's views and the conclusions of this thesis will be drawn out later, with specific emphasis upon how the developmental approach adopted here explicates why such "cognitive" difficulties are likely to put in their first appearance in adolescence. Other cognitive-behaviouralists have adopted positions similar to the one just outlined in that primary responsibility for the suicidal act is located at the juncture of maladaptive idiosyncratic beliefs and a constriction of thought which severely limits the consideration of alternatives. However, underlying these more general characteristics, and what is understood to be the central psychological core common to suicidal individuals is a overwhelming sense of hopelessness (Beck et al., 1984; Minkoff, Bergman, Beck & Beck, 1973). This sense of hopelessness is said to be manifested in suicidal persons by an attitude of general pessimism or negative expectancy in regard to their own personal future and has been found to be more predictive of suicidal intent than is depression, with which it is often correlated. On the strength of these findings, a measure of "hopelessness" was incorporated into the methodology of this study. SOCIAL-COGNITIVE DEVELOPMENTAL INTERPRETATIONS OF SUICIDAL BEHAVIOUR In contrast to the sociological, psychodynamic, and earlier cognitive accounts outlined above, the central hypothesis to be tested in this study was that suicidal adolescents would differ from their "normal" age mates in terms of their conceptual management of problems of personal continuity and epistemic doubt. The rationale for this hypothesis was rooted in a series of papers outlining the potentially negative or maladaptive consequences of cognitive difficulties associated with failures to successfully negotiate certain of the developmental tasks of the adolescent period. According to these earlier accounts (Chandler, 1975, 1987; Chandler, Boyes, & Moran, 1984; Chandler, Boyes, Ball, & Hala, 1986, 1987), the cognitive advances common to early adolescence carry with them, not only a range of obvious and well documented positive consequences, but also a series of disquieting realizations which can cost such young persons an earlier equanimity born of simple ignorance. Central among these important but disarming discoveries are the realizations: 1) that the grounds for assuming the persistence of one's own identity in the face of change are not self-evident or automatically guaranteed; and 2) that old confidences in presumptively shared certainties are unfounded. Earlier research efforts have demonstrated that these two issues become matters of focal concern in the lives of most adolescent youth, and that wide developmental and individual differences exist in the degree of success with which particular adolescents manage to resolve these problems. While both of these dimensions of difference also distinguish younger and older adolescents who function within the normal adaptational range, there are also good reasons to assume that special difficulties in resolving these developmental dilemmas will especially characterize young persons who make serious attempts to take their own lives. Why this should be so is detailed in the sections which follow. Identity Diffusion and Adolescent Suicidal Behaviour One of the organizing assumptions of this study is that, relative to their non-suicidal peers, young persons who have made serious attempts against their own lives will prove less able to successfully resolve questions of numerical identity in the face of change. The conceptual grounds for this hypothesis are located in a series of papers (Chandler et al., 1984; Chandler et al., 1986, 1987) which have had as their purpose the task of developing a descriptive account of the alternative ways in which young persons of varying ages undertake to warrant their own continuity across time. A number of philosophers (Maclntyre, 1981; Perry, 1975; Rorty, 1976) and social scientists (Gergen & Gergen, 1983; Harre, 1984) have argued persuasively that if the concept of selfhood is to have any coherent meaning, it must refer to a self that survives changes by somehow persisting through time. Such an account of personal identity, these authors claim, is fundamental to our everyday notions of personal reidentification, responsibility for our past actions, and concern for our own future well being (James, 1910). Erikson (1968), among others (e.g., Dobert, Habermas, & Nunner-Winkler, 1987; Rosenberg, 1984), has made such an achievement of personal continuity a prerequisite for a coherent sense of identity, and the formation of such a stable identity the central psychosocial task of adolescence. By these accounts, failure to maintain some diachronic connection or sense of continuity between one's own past, present, and potential future selves would leave no reason for one to act with any special care or concern for what would otherwise be understood as in one's own future interests. On the preceding logic, adolescents who have seriously entertained and acted upon the intention to end their own lives represent a group of individuals who, by their own actions, have demonstrated an extreme lack of commitment to their own future selves. Consequently, such self-destructive tendencies, it is argued here, may be understood as a partial consequence of these young persons having suffered extreme failures in their efforts to achieve an appropriate sense of personal continuity. Testing this theoretical possibility is a central task of the research to be reported here. How is Personal Continuity Warranted in the Usual Developmental Course? While the simple assertion that one persists in a self-same or numerically identical way through time is rarely called into open question, the private achievement of some conception of selfhood that actually allows for such a sense of connectedness across the physical, social and psychological changes to which we are all subject is often hard won, and in no sense is automatically guaranteed. What is required is some conceptual means of counting one's self as continuous despite and across such changes. Phrased somewhat differently, the task of achieving a sense of continuous personal identity amounts to the problem of identifying criteria by which one can count the conclusion of persistent identity justified. In principle, a number of different classes of justificatory criteria are potentially available which, if applicable, can serve to guarantee a certain personal connectedness across time. How adequate each of these different types of warranting strategies actually is depends, in some large measure, on the sorts of changes individuals reflect upon and, consequently, are required to take into personal account. The move into adolescence, it is argued here and elsewhere (Chandler & Ball, in press; Chandler et al., 1987), marks the beginning of a period of development during which young persons' self-reflective abilities are focused upon the sorts of dramatic physical, social, and psychological changes likely to undermine simpler physicalistic strategies by means of which personal continuity was once easily justified. As such, adolescents who find themselves confronted with an expanding horizon of personal change are routinely called upon to mount increasingly more adequate warrants of personal sameness. A typology of alternative continuity warrants Previous research (Chandler et al., 1987) has documented that the manner in which young persons undertake to warrant personal continuity progresses through a predictable and orderly age-graded sequence of increasingly adequate warranting strategies. These various types of continuity warranting strategies can be schematized according to the five-part typology summarized in Table 1. In brief, the first three types of continuity warranting strategies outlined here are predicated upon the common assumption that persistent identity rests upon, and is vouchsafed by the presence of, some structural similaritj' between one's roster of past and present attributes. The differences which divide these contrasting claims of identity through structural similarity hinge upon the alternative conceptions of self upon which they are based, and the ways in which each incorporates or resolves issues of manifest personal change. The simplest of these alternatives rests upon the assumption that one or more of one's defining attributes persist wholly unchanged despite other obvious transformations. Such simple inclusion arguments (level 1) discount the relevance of such manifest change and solve the question of numerical identity by pointing to counter-examples which appear to have somehow remained impervious to the workings of time. The obvious problem with claims of this sort is that as more and more of one's attributes undergo undeniable change the potential grounds upon which one's identity can be warranted are systematically eroded. Level 2 typological warranting strategies argue for self continuity by discounting all personal change as only apparent rather than real. Table 1 A Typology of Possible Continuity Warrants Structural Warrants Level 1: Simple Inclusion Arguments Conception of Self The self is seen as a static, composite collection or mosaic of juxtaposed attributes. Change amounts to the simple addition or deletion of parts. Level 2: Typological Arguments Conception of Self The self is conceived of as a typologic space, each facet of which represents another side of one's fixed character. Change is considered merely presentational and should be discounted as only apparent. Level 3: Essentialist Arguments Conception of Self The self is conceived of as a hierarchicalized system governed by deep lying essential attributes. Change is considered phenotypic, only occuring in surface attributes, but not in the essential core of self. Grounds of Continuity Claims A "sufficient" number of attributes characteristic of one's former self are assumed to co-occur in one's self of the moment. Grounds of Continuity Claims Facets of one's character are sometimes eclipsed from view but, although hidden, remain as fixed features of the architecture of the self. Grounds of Continuity Claims Phenotypic changes are rationalized as alternative manifestations or paraphrases of a common, unchanging essential core of one's identity. Functional Warrants Level 4: Foundational Arguments Conception of Self The self is understood as a network of relations of implicative mediation tying the present to its ancestoral past. Changes may be structural but are seen to constitute the conditions of satisfaction of a determining past. Level 5: Narrative Arguments Conception of Self The self is conceived of as an autobiographical or narrative centre of gravity. Changes may be structural and these structural changes are matched by changing constructions of the narrative meaning of the self. Grounds of Continuity Claims The novel aspects of the person one has become are seen to be coherently connected to the person one once was because it would be logically impossible to become the latter without previously having been the former. Grounds of Continuity Claims The narrative that constitutes one's autobiographical self is counted as continuous so long as it makes possible a coherent and followable network of interpretable connections. Such level 2 strategies are based upon the more complex typologic vision of selfhood as a sort of solid, polyhedronic space formed by many planar surfaces, each one of which is imagined to reference another facet of one's fixed identity. Authentic change, by these accounts, is denied and apparent change is explained away on the grounds that any newly manifested aspect of the self is a consequence of the illumination of certain particular personal attributes which were always present but previously eclipsed from view. Such typologic claims are both fatalistic and incapable of facilitating the creation of a coherent or integrative biographical account which incorporates manifest qualitative change. Level 2 warrants, then, are perfectly capable of preserving sameness but only at the cost of flatly denying the possibility of real change. Essentialist warrants (level 3) represent the first of these alternative strategies which is capable of simultaneously acknowledging real change and preserving personal sameness through time. Exponents of such essentialistic views conceive of identity as rooted in a hierarchically organized self-system, the component parts of which are understood to occupy more than a single level of abstraction or internality. By this accounting strategy the more central and defining of one's attributes are thought to underlie and inform their various surface manifestations which, for their own part, are taken to be mere phenotypic appearances. So long as one is able to rationalize the conclusion that there is at work beneath one's surface attributes some inner core of essential sameness capable of productively paraphrasing itself in variously phenotypically diverse but genotypically equivalent forms, real differences can be acknowledged while continuous identity is still preserved. Such strategies are relatively robust in that the changing features of oneself can, in principle, be continuously reinterpreted as different expressions of an ever deeper lying inner abstract core. The sorts of problems that eventually arise for individuals relying on such essentialist claims to continuity are that as new differences arise on the scene, the search for some interior esssence capable of subsuming such phenotypic changes is moved to increasingly remote levels of abstraction until all that is left is a nameless pointing operation long on generality but short on interpersonal currency - some secular equivalent of a featureless but immutable soul. In contrast to the three types of structurally based warranting practices outlined above, the last two continuity conferring strategies depicted in this typology abandon as unnecessary all assumptions about the persistence of shared parts and substitute in their place a thematic conception of persistence identity that is rooted in various relations thought to obtain between the diverse episodes of one's own life course. Both foundational arguments (level 4) and narrative continuity arguments (level 5) rest all claims for the persistence of selfhood on the assumption that the person one once was and the person one has or will become are functionally rather than structurally related. The main dimension of difference which divides these two functionally based types of warrants is the degree of constraint each imposes on one's changing conceptions of oneself. Level 4 foundational arguments claim continuity on the grounds that one's present self is the logical outcome of one's own ancestoral past. In this manner, the individual is seen as a coherently connected product of a determining past whose potential future selves become increasingly constrained by the canalization of time. Narrative arguments (level 5), on the other hand, free individuals of the constraining aspects of a determining past by resting claims of continuity entirely on the basis of a self-recognized interpretive process for which the criteria for continuity is the successful construction of a coherent and followable network of interpretive connections between the various manifestations of one's diachronic self. Continuity and Suicidal Behaviour Earlier research (Chandler et al., 1987) has demonstrated two critical points relative to the development and application of such continuity warrants in adolescence. First, it has been shown that structurally based level 3 essentialist arguments, which rely on the creation of a levels distinction separating surface change from essential sameness, and levels 4 and 5 functional arguments, capable of justifying relational connections between earlier and later ways of being, typically are not available to young persons who lack the kinds of abstract processes of thought associated with formal operational reasoning (Piaget, 1970). Second, it has been demonstrated that what adolescents commonly count as defining features of their own identity are precisely those level 1 and 2 surface attributes which are most in transition during their teenage years. The confluence of these two restrictions upon earlier methods of warranting personal continuity all but guarantee the prospect of an important crisis of identity for all those young persons who continue to stake their claims to identity upon inherently transient features of their own personality make-up. It also follows that adolescents will be able to justify their own temporal coherence only to the extent that they abandon such simple inclusion and typologic arguments for personal continuity in favour of more essentialistic and functional styles of justificatory reasoning. Such prospects open up the possibility that for certain youth that have failed to acquire these more mature modes of warranting continuity, the usual changes associated with adolescence are likely to disrupt their sense of connectedness across time. In the extreme, the lack of adequate means to understand their own numerical identity may cost such young persons interest in their own continuing personal history. If, as Erikson (1968) and others (Dobert et al., 1987; Rosenberg, 1984) argue, a sense of selfhood and a stake in our own past and future require a sense of personal continuity, and if certain youth lack the capacity to successfully mount such continuity warrants, then for such individuals identity crises are inevitable. In particular, such individuals are likely to lack a sense of commitment to their own past and future selves and to act in ways that do not show proper concern for their own future well being. On these grounds it was hypothesized that adolescents without an effective means of warranting their own personal continuity would be at risk to various self-destructive behaviours, and conversely, that as a group, suicidal youth would demonstrate themselves less able to successfully warrant personal continuity than would their nonsuicidal age mates. Skeptical Doubt and Suicidal Behaviour in Adolescence Previous work (Boyes, 1987; Chandler, 1975; Chandler et al., 1986) has documented that the achievement of certain role-taking competencies common to the early adolescent period has the negative consequence of costing young persons their earlier sense of absolute conviction by confronting them with the apparent person-relative character of knowledge. According to this account, younger children are insulated by their own egocentricity from any clear awareness that different people find different meanings in what are for them common experiences. With the advent of mature role-taking competencies, however, such naively realistic views are naturally sacrificed to the better relativized appreciation that all persons are in some sense trapped behind the walls of their own subjectivity. Consequently, it has been argued, this growing sense of relativism promotes a kind of "Cartesian anxiety" (Chandler, 1987) according to which earlier case specific doubts about this or that truth claim are replaced by a more wholesale brand of generic uncertainty that renders essentially everything subject to doubt. The dilemma which this poses is that of finding some conceptual means of acting with conviction or commitment. In studies of normal adolescents, three alternative responses to the emergence of such skeptical doubts have been identified, each one of which differs in terms of how the problem of uncertainty is construed, what constitute the necessary criteria for acting with conviction, and how available these criteria are understood to be. Each of these alternative responses which have been more fully elaborated elsewhere (e.g., Chandler, 1987; Chandler et al., 1986) are detailed in brief in the paragraghs which follow and summarized in Table 2. Level one - defended realism. The first, and most early arriving, response to nascent skeptical doubt is referred to here as defended realism (level 1). By this account, alternative interpretations of reality are held to be the product of vested interests and private agendas which are understood to interfere with objective efforts to arrive at a shared truth. That is, the common search for certain knowledge is understood to be overrun by veiled interests or biases which operate on cultural, social, generational, and individual levels. The same prospect of bad faith is even extended to the self by persons at this first level, who recognize that they too are potentially guilty of distorting the truth in the service of their own situated interests. Interpretation of any kind, by this account, is a kind of social disease the only cure for which lies in finding some completely disinterested third party who, because he or she has no stake in the matter, is capable of viewing the situation objectively and thereby veridically. Because accomplishing this task is no easy matter and often ends up with experts that also disagree among themselves, such defended realists are commonly forced to abandon their efforts to run undisputed facts to earth. Table 2 Strateg ies for Dealing with Nascent Skept ica l Doubt Level C r i t e r i o n for Explanation of Response to Knowledge Claim Divergent Views D iver s i t y Defended Rea1i sm Absolute Personal biases and Certa inty vested Interests block the sort of o b j e c t i v i t y that would lead to a consensus of t ruth. Search for d i s i n te re s ted t h i r d party who can ob jec t i ve l y a rb i t r a te truth claims. Dogmatism/ Absolute Knowledge claims are Skepticism Certa inty inherently subject ive and amount to no more than personal opinions which can not be evaluated r a t i o n a l l y . (D) Search out some extra-personal source of ob ject i ve truth or (S) re jec t a l l r a t i ona l c r i t e r i a and r e l y , instead, upon noncognlt ive dec i s ion making s t ra teg ies . Post-Skept ica1 Rat iona1i sm Relat ive Knowledge claims are Certa inty inherently subject ive but standards of judgement can be found by which to evaluate such r a t i o n a l l y based truth claims. Search for r a t i ona l c r i t e r i a by which to choose between one truth claim and another. Level two - the dogmatic/skeptical axis. Individuals who have abandoned hope of divesting themselves or remedying others of personal bias are typically prompted to move in one or the other of two opposing but related directions, both of which fall along what is described here as the dogmatic-skeptical axis. Those who favour skeptical solutions reject as unrealistic all prospects of finding any acceptable cognitive means of choosing between important alternatives. Unprepared to assert or accept anything as true, such skeptics struggle to suspend all judgment about what it is that should be done and instead rely on various extra-cognitive decision-making mechanisms whenever decisions are forced upon them. Examples of such noncognitive decision-making strategies include impulsivism (acting without thought), intuitionism (doing what affect demands), conformism (doing the done thing), and indifferentism (tossing a coin). Dogmatists, who occupy the opposite end of this dogmatic-skeptical axis, share the skeptic's poor opinion about the prospects for personally generated knowledge, but resolve this dilemma by placing their faith in some extra-personal source of objective truth. Blind allegiance to religious dogma, or conversion to "scientism" and the canons of methodologic rigor are examples of such dogmatic solutions which are meant to provide some absolute corrective to the inherently subjective character of personally generated knowledge. The down side of these truth preserving commitments is that they tend, as do all dogmatic views, to have an all or nothing quality. Consequently, when any crack appears in such seamless pillars of faith their entire structure tends to come crashing down. The alternatives along this axis again reduce to another round of skepticism or a search for some new dogmatic faith. Level three - post-skeptical rationalism. A third alternative response to such persistent doubts is to abandon the search for absolute knowledge in favour of what amounts to a search for arguably good reasons for choosing one belief or course of action over another. Such post-skeptical views amount to an endorsement of the possibility and practicality of making rational commitments in the face of the clear knowledge that other defensible alternatives continue to exist (Chandler, 1987). By such an account, the lack of absolute certainty is not understood as an unsurmountable obstacle to making rationally based truth claims. Instead, individuals who hold to such post-skeptical views accept the reasonableness of identifying provisional standards of judgment that can be evaluated without recourse to the absolute unmitigated truth. The advantages afforded by such a post-skeptical solution include the freedom to envision a variety of defensible alternative life courses none of which need to be held out as being ultimately correct. Doubt and Suicidal Behaviour It has been argued elsewhere (Chandler, 1987; Chandler et al., 1986) that individuals whose development is foreshortened and whose response to uncertainty remains at level 1 (defended realism) or level 2 (the dogmatism-skepticism axis) are in highly vulnerable positions. Defended realists are forced to see everyone, themselves included, as the victims of their own petty biases. Dogmatists, by contrast, are vulnerable to the likely prospect that their authorities will fail them and skeptics are forced to leave things to whim, impulse, or convention, and consequently have little reason to invest themselves in their own capricious future. Fortunately, for many adolescents, these are not the only or usual alternatives. Instead, with increasing maturity, most young persons come to realize that it is not necessary to be more certain than certainty permits, and that it is possible to find good, if not ironclad, reasons for preferring one alternative over another, leading them to reject such realistic, dogmatic, or skeptical views in favour of some form of post-skeptical rationalism. ; While the foregoing account is meant to order the epistemic positions of defended realism, skepticism and dogmatism, and finally, post-skeptical rationalism along a common dimension of increasing formal adequacy, it does not follow as a consequence that only those adolescents who achieve the third or highest of these levels are insulated against the adaptational difficulties common to this developmental period. Such a conclusion might be successfully argued with reference to adults but, at least in Western cultures, there is a long precedent for assuming that adolescence is a staging ground on which young persons are meant to alternatively try out and reject various identities and provisional commitments (Marcia, 1983). On these grounds it can and has been argued that an epistemic posture of dogmatism or skepticism is entirely age appropriate for persons in this age group. The same thing may not be said of the position of defended realism, however. On the likely prospect that few persons reach adolescence without being made aware of the great range of divergent opinions that are held regarding almost every matter of moment, skepticism, and the dogmatic views that it sometimes fuels, while offering no rational solution to this conundrum, at least creates a certain sympathy for it. Those that deeply doubt the prospect of finding human ways of making personal commitments can scarcely avoid a certain empathetic resonance with others who they perceive to be adrift in the same boat. Quite the opposite is true, however, for the defended realist who persists in the view that there is a single and correct answer to every problem. For such individuals, two equally unattractive possibilities exist. Either no one as yet knows the real truth of some matter, in which case those that presume to tell one what to believe or how to behave are simply exercising their arbitrary authority, or the one and only correct belief has been identified but others persist, out of simple perversity or mean-spiritedness, to press their biased and wrong-headed case. In either instance the likely response is anger and frustration. For the two sets of reasons outlined above, two general hypotheses regarding the likely relation between personal adjustment and level of epistemic development are possible. First, and most generally, it is hypothesized that arriving at a mature position of post-skeptical rationalism will be more likely to occur among the normal adolescents of this study than among those who have been hospitalized as a result of psychiatric difficulties. Second, and more specifically, it is hypothesized that the hospitalized sample in general and the suicidal subjects in particular will be more likely to persist at the level of defended realism than will their better adjusted high school peers. SUMMARY OF HYPOTHESES The normative research upon which this study rests has demonstrated that in the course of adolescent development most young persons are forced, as a consequence of their increasing cognitive maturity, to come to terms with the issues of their own continuity in the face of personal change and the need to formulate commitments in an increasingly uncertain world. The hypotheses that have guided the present study centre on the general expectation that the inability to make adequate progress on these two central developmental tasks predispose a certain subgroup of adolescents to lose faith in their own future prospects and costs them all serious commitments to themselves and their own future welfare. The group of young persons who, through their own actions, appear to most clearly qualify for such dubious distinctions are those who have undertaken to end their own lives. On the strength of this argument a plan was undertaken to identify such a group of suicidal adolescents and to test them with the expectation that they would distinguish themselves from their nonsuicidal age mates by being less able to deal with matters of uncertainty and doubt, and their own continuous identity through time. Two realities of the present undertaking served to complicate this otherwise straight-forward prediction. The first concerns the fact that the developmental route along which young persons typically move in coming to a mature sense of continuity and commitment is marked by a sequence of intermediate levels or stages the achievement of which are correlated with but not specified by increasing chronological age. This fact, combined with the reality that the ages of the suicidal subjects to be studied could not be specified in advance, necessitated • that the hypotheses to be held up for specific test could not be stated in any simple either/or fashion, but needed to be formulated instead in a rather less precise language suggesting that suicidal subjects would show developmental delays in moving through these progressions relative to their nonsuicidal age-mates. The second difficulty that intruded into the crisp formulation of hypotheses to be tested in this study arose as a function of the fact that, for reasons that were neither anticipated nor are fully understood, it proved to be impossible to clearly identify a group of psychiatrically hospitalized adolescents that were entirely free of evident risk to suicide. As will be described more fully in the methods section that follows, all but one of a series of 35 consecutive admissions to the psychiatric facility from which the adolescent subjects of this study were drawn carried with them psychiatric histories that included some reference to the possibility of suicidal risk. As a consequence of this fact, the comparison groups that proved available did not include, as originally planned, a nonsuicidal, though psychiatrically hospitalized control, but are made up instead of a high suicide risk group, a low suicide risk group, and a set of matched normal control subjects. Given these various considerations, the specific hypotheses to be tested were as follows: 1) With respect to the measure of personal continuity a) nonhospitalized subjects were expected to show more mature continuity warrants than all hospitalized subjects taken as a group; b) high risk subjects were expected to show less adequate strategies for warranting personal sameness than other psychiatrically hospitalized subjects at low risk to suicide; and c) the normal control, low risk, and high risk subjects were expected to be distinct from one another and ordered with respect to their ability to justify their own numerical identity. 2) With respect to nascent skeptical doubt a) nonhospitalized subjects were expected to evidence more mature strategies for dealing with emergent skeptical doubt than were the hospitalized subjects; b) none of the hospitalized subjects were expected to make use of post-skeptical solutions to the problem of doubt; and c) high risk subjects were expected to persist with level 1 defended realist strategies. 31 CHAPTER 2: METHOD MEASURES While not unique to this project, several of the measures employed in this study are not widely known and, consequently, will need to be described in some detail. Following this presentation, a briefer and more conventional summary of the particular tasks, subjects, and procedures is offered. The first part of this method section, then, describes the measures employed in operationalizing the constructs of numerical identity and skeptical doubt. In addition, a description of the means by which psychiatrically hospitalized youth were subdivided into high and low risk suicidal groups is detailed. Measuring Numerical Identity The numerical identity measure employed in this study was developed by Chandler and his colleagues (Chandler, Boyes, Ball, & Hala, 1985) and involves a set of procedures for systematically interviewing subjects about how they understand the radical changes that take place in their own lives and in the lives of third party story characters. Simplified versions of Charles Dicken's "A Christmas Carol" and Victor Hugo's "Les Miserables" are presented in colour-illustrated booklets followed by a standard interview. Subjects are asked to first describe the ways in which these story characters are different at the beginning and the end of the story and then to warrant the conclusion that they are numerically identical with themselves throughout the stories despite these changes. Following this inquiry into the continuity of the lives of these fictional characters, a series of questions are posed regarding subjects' understanding of their own persistent identity. For this purpose, subjects are asked to describe themselves as they presently are and as they recall themselves to have been 5 years ago. Having offered these two self portraits, subjects are asked to justify their assumption that they continue to be one and the same person despite all the changes they have chosen to highlight. An outline of the standard interview procedure is presented in Appendix A. Responses to each of these three continuity problems are then scored with reference to the five possible classes of continuity warrants outlined in Table 1 according to criteria set out in Chandler and Ball (in press). This scoring system allows for the assignment of one of fifteen possible scores to each of the continuity warranting opportunities. Five of these scores correspond to modal instances of the five, classes of continuity claims already described. The remainder correspond to transitional versions of these warrants, including two which represent complete failures to justify persistent identity, either by offering no warrant whatsoever or by immediately discounting all such warrants already presented. The total score assigned to each subject represents their averaged score across the three continuity problems. Measuring Skeptical Doubt The work of researchers such as Perry (1970) and Kitchener and King (1981) have shown that college students commonly come to entertain serious doubts about even the most expert of knowledge claims. As a means of documenting this fact, these authors have undertaken to demonstrate, that many well educated young adults appreciate that experts often attach irreconcilably different meanings to the "same" event. These earlier measurement efforts have employed open ended interview procedures and have tended to focus attention upon issues of a rather abstract, technical or academic nature which are remote from the everyday lives of most adolescents. As such, the procedures utilized in these earlier studies hold out little hope of illuminating the nature of issues of uncertainty as they may unfold over the course of the adolescent years and may have seriously underestimated the age at which such concerns first emerge. In support of this possibility, the work of Broughton (1978) and Mansfield and Clinchy (1985), and, less directly, that of Turiel (1983) and Smetana (1983, 1985) have indicated that when asked about more familiar matters, adolescents are often quick to characterize competing knowledge claims as debatable matters of taste, opinion, or simple social convention. While pointing to the likelihood of early emerging doubts, these efforts do not directly address the question of when young persons first become capable of entertaining the serious skeptical doubts which are of interest in this study. For these reasons, and in light of the previously outlined conceptual analysis, which strongly suggests that such skeptical doubts first put in their appearance in the early adolescent years, measures were devised for the purpose of documenting emergent skeptical doubt in adolescence (Chandler et al., 1986). These measures have subsequently been validated on a normative sample of elementary and high school children (Boyes, 1987). Nascent Skeptical Doubt Interview Procedure. The form which these measures have taken is a set of two story dilemmas which pit the knowledge claims of one group against those of another. The two stories vary in terms of the status of each of the groups. Thus the stories are comprised of: 1) reports by two groups of experts expressing different points of view regarding the same social issue; and 2) an article generated by a group of parents contrasted with a student authored article regarding the same school policy issue. The content of each story was designed to be of interest or relevance to young adolescents, and to concretize these "disagreements" as much as possible. Accompanying each story is a series of questions or probes designed to elicit subjects' thoughts about the nature of, the reasons for, and the possible ways to resolve such disagreements (see Appendix B). Using the Nascent Skeptical Doubt Scoring Manual (Boyes, 1987), responses are then scored as to whether they illustrate an awareness of the relativistic nature of thought (story construction) and, if so, which of the three possible strategies for dealing with this awareness is being used (story resolution). From these two subscores, a single score is derived for each story. Finally, subjects whose scores are not identical across the two dilemmas are assigned the average of the two global story scores. In this manner it is possible, in principle, for individuals to be categorized either into one of four "pure" levels: level 0 - naive realist position; level 1 - defended realist position; level 2 - dogmatism-skepticism position; level 3 - post-skeptical rationalist position, or one of three transitional levels. Based on the conceptual derivations of these levels as well as previous empirical results which have documented the age-graded sequencing of the responses to doubt (Boyes, 1987; Chandler, 1987; Chandler et al., 1986), the adolescent participants in the present study were expected to display responses that varied between levels 1 and 3 in this typology. Nascent Skeptical Doubt Questionnaire. In addition to the semi-structured interview procedure outlined above, a second and converging paper and pencil measure was developed by Chandler, Banerjee and Ball (Banerjee, 1986) which utilized a graded agreement response format. This more objective measure consists of a series of 20 attitudinal statements designed to express either extremely relativized or extremely realistic positions regarding the possibility of absolute knowledge or certainty with reference to a number of common topics (see Appendix C). For each item, respondents are asked to indicate, on a scale of 0-3, how dissimilar or similar a particular statement is to their own personal view. Half of the items are phrased as realistic attitudes and half are relativistically phrased views. Questionnaire responses are then matched to an all skeptically phrased item key and individuals are assigned a number between 0 and 3 corresponding to their averaged response across all items. Previous versions of this objective measure were piloted on samples of both university and high school students. The results of these efforts lead to the 20-item test used in the present study. The inclusion of this questionnaire as part of the testing procedure was meant to serve two purposes. The first and most immediate purpose was to investigate the usefulness of such an objective measure by administering it to individuals who were also being assessed via the more time consuming and interpretive interview method. By doing so, it was possible to evaluate how well the questionnaire discriminated between persons differentially categorized by the interview procedure. With this purpose in mind, the present study offered the opportunity not only to make this comparison across a varied age range but, in addition, to make it in light of the hypothesized differences between the clinical and nonclinical groups of adolescents being studied. The limitation here, of course, is that the present study does not provide for the large scale samples that would be required for a full assessment of the properties of the instrument. Consequently, the use of the questionnaire in the present context may be seen as a specialized piloting project. Measuring Degree of Suicidal Risk The admission and discharge summaries of each of the hospitalized subjects was reviewed in detail. It became apparent, under close inspection of these records, that what counted toward particular patients being labelled as suicidal varied considerably from one case to the next. It also appeared that there was pressure in favour of over-inclusion with regard to suicidal risk. This was likely due to the fact that the consequences of any suicidal gesture are so potentially tragic and irreversible that the most reasonable course is to label as suicidal all individuals for whom there was even a remote possibility of their seriously considering suicide. While probably generally true, it was particularly likely that something of this sort was operating in the context of the Adolescent Unit where the individuals in question were young persons for whom parents and professionals feel an especially heavy weight of responsibility. Such practices, while clinically sound, are not helpful to a research enterprise that requires some means of discriminating between persons who pose only a minimal threat to themselves, and those individuals for whom the taking of their own life seems a real and imminent possibility. In light of the hypotheses which have guided the present research project, some such discrimination was considered essential. To this end, a number of steps were taken in an effort to discriminate subjects who were at high and low risk to suicide. First, a four point categorization scheme was laid out which operationalized what was meant by various degrees of suicidal risk (see Appendix D). Each of these four levels was meant to be a concluding statement of risk based upon the combination of three main factors: 1) details of suicide attempt(s) (i.e., whether there was an explicit attempt, how many, when, surrounding circumstances, lethality, intent, etc.); 2) current expression of state (i.e., whether currently threatening suicide, specificity of threats, self or other reports of suicidal ideation, etc.); and 3) degree of professional concern (i.e., highlighting of suicide risk, special suicide precautions taken, suicidal behaviour considered in light of histrionic style, etc.). This scale served as a means of categorically assigning all of the hospitalized subjects to one of four risk levels ranging from those considered at extremely low risk for suicide (level 1) to those considered to be in great danger of commiting suicide (level 4). Secondly, procedures were set up in co-operation with the hospital staff to access the sorts of information required to categorize individuals according to the scheme outlined above. For this purpose, access was granted to the complete, ongoing hospital charts, which included summaries of personal history, initial interviews, details of admission, and daily nursing records, as well as to the discharge summary charts which included the final psychological and psychiatric reports for each subject. All of this information was painstakingly reviewed in each case, and all relevant information transcribed on to summary record sheets. The final step in this procedure was to assess whether individuals could be reliably scored according to this scheme on the basis of the available information. To test this, two independent judges familiar to the categorization of risk scheme, read the summary record sheets for each of these young patients and, on the basis of that information, -categorized them into one of the four levels of risk. There was complete agreement on 26 of the 29 cases (89.7%). Each of the three disagreements were categorized by the two raters into adjacent levels. The final category assigned in these three cases was decided through discussion. PROCEDURAL SUMMARY Subjects Thirty-five adolescent inpatients of the Adolescent Psychiatric Unit of the Vancouver General Hospital were nominated, over a period of 11 months, as potential participants in this study by professional members of the hospital's Psychological Services Department. The inclusionary criteria for nomination were: 1) written, informed parent/guardian consent for the young person to participate (written, informed personal consent was subsequently required of each participant); 2) the professional judgment by their attending psychologist, in the form of written consent, that participation would not be contrary to the best therapeutic interests of the individual; and 3) that the young person was professionally assessed to be of at least normal intelligence. Of the 35 consecutively admitted adolescents who met these criteria and who were then informed in detail of the nature of this study, with emphasis laid upon both its disassociation from hospital assessment and treatment, and upon the voluntary nature of their own involvement, 30 agreed to participate. Upon review of hospital discharge summaries, it was learned that for one of the adolescents tested there was some concern regarding possible brain damage despite an assessment of within-normal-range intellectual functioning. This youth was dropped from the study leaving a total sample of 29 hospitalized adolescents between the ages of 13 and 18 years. Twenty-nine student volunteers drawn from public schools in the Vancouver area, and for whom written, informed parent/guardian and personal consent were obtained, also participated in the study. Student volunteers were selected to match as closely as possible their hospitalized peers in terms of age, sex, family occupational status, and general intelligence. Since no formal intellectual assessments of the high school adolescents were available to serve as a check on this last selection variable, individuals who were in grade levels lower that normally appropriate for their age were excluded. The average age of the hospitalized group was 15.33 years (183.96 months, SD= 14.71) which was almost identical to that of the nonhospitalized group whose mean age was 15.30 years (183.62 months, SD= 15.57). There were 10 boys and 19 girls in each of the two groups. For both the hospitalized and the high school samples, the boys tended to be slightly older on average (X= 188.0 months, SD=12.4 and X= 188.4 months, SD=13.7 respectively) than the girls (X= 181.8 months, SD=15.7 and X = 181.1 months, SD=16.2 respectively). Information on parental occupation was gathered on each of the young psychiatric patients and coded according to the Standard International Occupational Prestige Scale (Treiman, 1977). The scale has a range of 92 points, from -2 (gatherer) to 90 (chief of state) with a mean scale score of 43.3 (SD=16.9). The mean of the occupational scores for the hospitalized group was 41.62 (SD= 11.79). When information on both parents' occupations was available, the average of these scores was used in calculating the overall mean. Mothers' (n_=21) occupation scores ranged from 16 (living on public assistance) to 57 (elementary school teacher) with a mean score of 39.81 (SD= 10.93). Fathers' (n = 22) occupation scores ranged from 26 (farm labourer) to 71 (lawyer in private practice) with a mean score of 44.4 (SD= 13.08). In general, a diverse range of occupations were held by the parents of the hospitalized adolescents with professionals, self-employed business people, and skilled, semi-skilled, and unskilled labourers all represented. Equivalent information was not available for the high school sample. However, an attempt was made to approximate a broad range of parental backgrounds by selecting the students from two different high schools. Approximately two thirds of the high school sample were drawn from a school in a high rental, lower-middle to middle class area while the remaining one third were drawn from the school in a predominantly middle to upper-middle class section of the city. Materials The measure of numerical identity used was the Continuity Measure as revised by Chandler and Ball (in press). This revised version developed out of refinements of earlier work by Chandler, Boyes, and Moran (1984) and Chandler, Boyes, Ball, and Hala (1985). The story presentation and associated semi-structured interview procedure, aimed at determining subjects' characteristic manner of accounting for personal continuity in the face of change, have been detailed in the previous section. The two measures designed to assess subjects' awareness of, and characteristic responses to, conditions of uncertainty and doubt employed in this study were the Nascent Skeptical Doubt Interview procedure originally developed by Chandler, Boyes, Ball, and Hala (see Boyes, 1987; Chandler et al., 1986), and the Skeptical Doubt Questionnaire developed by Chandler, Banerjee, and Ball (Banerjee, 1986). A description of these two measures and the rationale for their use have been outlined in the preceding methods section. In addition to the measures outlined above, the standardized 20-item paper-and-pencil Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) was administered to the psychiatrically hospitalized adolescents. This procedure was not given to the high school students on the grounds that there is evidence to suggest that social desirability response biases contaminate the scale results when used with nonclinical samples (Linehan & Nielsen, 1981) but do not seem to present this problem when used with clinical samples (Petrie & Chamberlain, 1983). The Hopelessness Scale was designed to be an easily administered measure of negative expectancies meant to correlate with clinical ratings of depth of hopelessness which, in turn, are meant to correlate with degree of suicidal risk. Since this scale has been used most often with adults it was included in the present study not as the primary measure of suicidal risk, but rather a convergent assessment strategy which, if it was found to correlate highly with other indices of risk, would be informative both of the usefulness of the scale with suicidal youth, and perhaps of certain characteristics of these young hospitalized patients. For each of the twenty statements which comprise this scale, subjects were asked to indicate whether that statement does (true) or does not (false) describe their attitude over the preceding week. A score of one was assigned to each response that matched the key (pessimistic responses) and a score of zero was assigned otherwise. Following Beck et al. (1974), each subject was then assigned their total summed score which was meant to measure their sense of hopelessness according to the following guidelines: 0-3 none or minimal; 4-8 mild; 9-14 moderate; and 15-20 severe. Procedure Each of the psychiatrically hospitalized adolescents was seen individually in a room provided by hospital personnel on the premises of the Adolescent Unit. Due to the special circumstances which defined this subject population, great care was taken to describe the purpose and limits of this project and to emphasize the voluntary nature of both their initial consented participation and their continued co-operation. Each young person was seen for approximately one and one half hours during which the skeptical doubt measures, the continuity measures, and the hopelessness scale were administered in randomized order. All but one subject chose to remain throughout the entire testing procedure. While it was originally planned that the hospitalized subjects would be seen within two weeks of their admission to the Unit, hospital procedures and professional judgments of subjects' readiness made it impossible to adher strictly to this criterion. Instead, these young persons were seen anywhere from 5 to 28 days after admission (X= 15.24 days, SD = 5.55). All testing done on the Unit was carried out by either Dr. Chandler or myself. Adolescent volunteers selected from the Vancouver public school system were likewise seen individually in a room provided by their school. The format of these interview sessions were identical to those with the special population as described above with the exception that the Hopelessness Scale was not administered to this group for the reasons already outlined. Interviews were scheduled at the convenience of the school personnel and the individual student. All testing sessions were audio tape-recorded and later transcribed. All scoring was done from these. written transcripts which were identified by code only. Strict confidentiality with respect to all aspects and in all phases of this project was maintained throughout. SCORING Due to the interpretive nature of the scoring procedures involved in the two primary measures employed in this study, it was necessary to establish again that such scoring could be done in a consistent manner by independent judges. To this end, two raters, trained in the scoring of the Nascent Skeptical Doubt Interview, independently coded 15 randomly selected protocols of the doubt section of the procedure. Thus, each rater coded a total of 30 story dilemmas on both subjects' constructions and resolutions of the presented problems. Both raters were blind to the relevant statuses of the adolescents whose protocols they scored. Interrater reliability between the two judges was considered adequate (total absolute agreement = 85.71%) and disagreements were resolved through discussion. The remainder of the transcripts were coded by the author of this thesis, still blind to the ages and suicidal statuses of the subjects. A total of 57 transcripts were available for coding as one subject requested withdrawal from the procedure prior to completing the doubt interview. The majority (72%) of subjects were found to score at the same level on both of the story dilemmas, and no subject obtained scores that were more than one level apart. Interrater reliability was assessed in a similar manner for the Continuity Measure. Half of the total number of protocols were scored independently by two trained raters blind to the relevant statuses of the subjects. A high level of agreement was obtained across the two judges (94% agreement) and again disagreements were resolved through discussion. As with the doubt interview, the remainder were scored by the author, still blind to the ages and suicidal status of the subjects. Nine subjects (8 control and 1 hospitalized) did not complete all three sections of the interview. However, based on the remaining 49 interviews, an assessment of response consistency across the three warranting opportunities indicated that the measures and coding procedures captured a consistent interpretation of subjects' continuity claims (Kendall's Coefficient of Concordance, W = .93, %* (48) = 134.31, JD<.0001). While there was some variation in individuals' scores across the three measures, none of the subjects' scores varied by more than one adjacent level. The last measure to be coded which required interpretive scoring was the assessment of suicidal risk. The specifics of that procedure have already been described in some detail and all that will be added here is a brief summary by way of reminder. Two independent raters each coded all of the 29 hospitalized adolescents into one of four categories of risk on the basis of information recorded on each individual's summary record sheet. No information regarding subjects' scores on either the doubt or continuity measures was contained in these records. Complete agreement was obtained in 89.7% of the cases. Each of the three subjects about whom there was disagreement was coded by the raters into adjacent scoring levels. Final categorization was determined, once again, through discussion. Of the 29 hospitalized subjects, 9 were coded at the lowest level of risk (level 1), 7 were placed into the second lowest risk category (level 2), 8 were scored as belonging to the second highest category (level 3), and 5 were coded at the highest level of risk (level 4). Levels 1 and 2 were then collapsed to form the low risk group (n=16) and levels 3 and 4 combined to form the high risk group (n= 13). There were equal numbers of males in each of the two final risk categories, but there were slightly more female adolescents in the low (n = 11) than in the high (n_=8) risk groups. Overall, the distribution of males and females closely conformed to the 1.9:1 female-to-male ratio selected for in the high school sample on the basis of the overall sex ratio in the hospitalized group (Mann-Whitney U-test, j_=-.13, JD>.89 across all three groups). In addition, one-way analyses of variance indicated no significant differences between the high and low risk groups in parental occupational prestige (F(l,27) = .0773, _p_>.78) or subject age (F(l,27) = .6748, _p_>.41). The mean ages of the high and low risk groups were 181.5 months (SD = 14.02) and 186.0 months (SD = 15.39) respectively. An inspection of the distribution of diagnoses across the four risk categories indicated that increased level of suicide risk was not directly associated with severity of emotional disturbance or any one particular diagnostic label, although depression was featured more often among the higher versus lower levels of risk (see Table 3). The Hopelessness Scale scores were not used in the assessment of suicidal risk. It was originally anticipated that these scores might provide a convergent measure of degree of risk. However, given what proved to be the negative, but statistically non-significant, correlation between the four clinically based levels of increasing risk and increasingly higher (more pessimistic) scores on the Hopelessness Scale, subjects' scores on this scale were not taken into account in the judgment of suicidal risk. The obtained correlation between individuals' actual total score on the Hopelessness Scale and assessed level of risk was -.31 (Spearman-rank, jo>.06). Using the published cut off scores provided with the scale to categorize subjects into one of four levels of hopelessness (none; mild; moderate; severe) the same non-significant relation to suicidal risk category obtained (rho = -.29, jo>.06). Table 3 Discharge Diagnosis by Suicidal Risk 45 Discharge Diagnosis (DSM III: Axis 1) Rating of Suicidal Risk l(low) 2 3 4(high) conduct disorder attentional disorder school refusal adjustment disorder post-traumatic stress obsessive compulsive dysthymic major depression/ depression bipolar depression schizophreniform a-typical psychosis schizophrenia psychotic 2 1 0 0 1 3 2 1 5 0 0 CHAPTER 3: RESULTS Prior to assessing, through comparative analyses, the anticipated differences between the variously suicidal and the nonsuicidal groups, it was necessary to determine the degree to which the normative sample conformed to the theoretic expectations outlined earlier in the introduction, and to previous empirical results obtained with other high school samples (Boyes, 1987; Chandler et al., 1987). Consequently, this section begins by first detailing the results of an assessment of the extent to which the present normative sample conforms to more general developmental expectations. Following a description of these results, the outcome of a series of comparative analyses aimed at describing the ways in which suicidal and nonsuicidal youth deal with the issues of personal continuity and nascent skeptical doubt is detailed. The Normative Sample as an Appropriate Comparison Group Warrants of Personal Continuity The routine expectation of any developmental sequence relevant to the range of ages under study is that increasingly higher levels ought to be generally associated with a corresponding increase in age. In the present sample a moderate but significant correlation was obtained between the high school students' averaged continuity scores and their chronological ages measured in months (r = .45, JD<.008). An examination of Table 4 indicates that the large majority (87%) of the older subjects (X= 16.34 years old, SD = .63) made use of the more mature essentialistic and functional warranting strategies, whereas only slightly more than a third (36%) of the younger members of this sample (X= 14.18 years old, SD = .77) employed these higher level arguments. In addition, although 4 of the youngest of these subjects still relied on the most primitive of the Table 4 Type of Continuity Warrant by ( n o n - h o s p i t a l i 2 e d sample) Age Type of Warrant Subjects 1. Simple Inclusion 3. Essentialist Dichotomized 2. Typological 4. Functional by Age Younger 9 5 (n=14) (64%) (36%) Older 2 13 (n=15) (13%) (87%) E=.O06 (Fisher's Exact) H=29 continuity warrants (level 1 simple inclusion claims), none of the older group were found to do so. While the mean rank of the average continuity scores employed by the somewhat older male subjects was slightly higher than that of the females, both sexes were generally evenly distributed across the range of obtained scores (Mann-Whitney U-test, _z_=-.48, jp_>.62). The continuity data generated by the present normative sample were found generally to conform then to that produced by other comparable samples (e.g., Chandler et al., 1987). Strategies for Dealing with Nascent Skeptical Doubt As expected, none of the 29 high school students responded to the Nascent Skeptical Doubt interview procedure with reasoning scored at a pure level 0 (i.e., naive realist positions). In fact, only one young subject evidenced any level 0 reasoning at all. This finding was consistent with the expectation that within a sample for which at least transitional formal operational competencies might be anticipated, subjects ought to express, at minimum, a beginning awareness of the subjective character of knowledge. Table 5 arrays the percentage of high school adolescents by the highest of each of the three alternative strategies of which they were found to make use. As can be seen from an inspection of Table 5, almost half (48%) of these students interpreted the situations in skeptical and dogmatic terms (i.e., employed level 2 strategies). The remaining half were almost evenly split between defensive level 1 strategies (defended realist positions) concerned with justifying the possibility of absolute truth, and level 3 (post-skeptical rationalist) solutions which embrace the possibility of finding rational criteria for resolving matters of uncertainty. Again, these results are consistent with theoretical expectations and with previous related findings in that all three strategies were in evidence in this 13- to 17-year-old high school sample, with the most typical responses falling into scoring category two (see Boyes, 1987). 49 Table 5 Responses to Nascent Skeptical Doubt (non-hospitalized sample) Type of Strategy Level 0 Level 1 Level 2 Level 3 Naive Defended Dogmatism- Post-Skeptical Realism Realism Skepticism Rationalism 0 (0%) 7 (24%) 14 (48%) 8 (28%) N=29 Finally, the use of increasingly mature responses to uncertainty was associated with increasing age (r = .35, JD<.04). While the present sample was not selected to bring out such developmental trends, the data generated does conform to the generally anticipated age relation, with the older of these subjects more frequently making use of dogmatic/skeptical (60%) and rational (33%) strategies. In contrast, almost half (43%) of the younger group still relied upon defensive level 1 solutions, and only one fifth (21%) evidenced level 3 rational solutions. Table 6 summarizes these general age associations by contrasting those subjects who showed evidence of appreciating the relativized nature of the problem (levels 2 & 3) with those individuals who held to a simpler defended realist position (level 1). As illustrated in Table 6, all but one of the older subjects made use of at least a level 2 strategy (93%) whereas only approximately half of the younger subjects (57%) did so. Males, who were somewhat older, tended to score at somewhat higher levels than did female adolescents (Mann-Whitney U-test, _z=-2.12, j><.04). Based on the above analyses, the high school students selected for participation in this study were considered to conform to theoretically and empirically derived expectations on both of the measures of central interest to this thesis. On these grounds the high school sample was judged to be an appropriate normative group for subsequent comparisons involving the hospitalized subjects. In light of the experimental nature of the Nascent Skeptical Doubt Questionnaire no such comparative analysis was possible. Continuity and Suicidal Risk A Kruskal-Wallis one-way analysis of variance by ranks carried out with the averaged continuity scores of the 58 subjects grouped by level of suicidal risk (high school controls, low risk, high risk) indicated significant differences between groups in the types of warrants employed Table 6 Response to Nascent Skeptical Doubt by Age (non-hospitalized sample) Type of Strategy 51 Subjects Dichotomized by Age 1. Defended Realism 2. Dogmatic/Skeptical 3. Rational Younger (n=14) 6 (43%) 8 (57%) Older (n=15) 1 (7%) 14 (93%) B=.03 (Fisher's Exact) N=29 (Xl(2)= 18.88, jp_<.0002), with the high school sample obtaining the highest mean rank (38.48) and the high risk subjects obtaining the lowest mean rank (15.12). Mann-Whitney U-tests further demonstrated significant differences both between the high school and low risk groups (z = -3.10, J25--001), and between the low risk and high risk groups (z = -2.50, _p_<.02). In short, membership in graded levels of increasing suicidal risk was found to be associated strongly with corresponding immaturity in the types of continuity warranting practices employed. As was discussed earlier, it was also anticipated that: 1) the nonhospitalized subjects would rely primarily upon essentialist (level 3) and functional (levels 4 or 5) continuity warrants; 2) the low risk group would score primarily at levels 1 and 2 (simple inclusion and typological continuity warrants); and 3) that the high risk group would show little or no ability to count themselves continuous through time. Table 7 arrays these three risk groups against their proposed levels of continuity warrants. Several important results can be observed in Table -7. First, and-most striking, was the finding that almost 80% (10 of 13) of the high risk suicidal subjects were wholly at a loss to understand how they or others could change in important ways and still persist at being themselves (i.e., level 0). By contrast, only one of the low risk suicidal adolescents (6%) and none of the high school subjects found themselves without any such means of justifying a sense of personal continuity through time. Secondly, while almost all of the low risk suicidal adolescents evidenced some strategy for conserving selfhood in the face of change, only 2 of these subjects (13%) employed warrants more sophisticated than levels 1 and 2 which effectively discount or deny personal change. By contrast, 62% (18 of 29) of high school adolescents made use of warrants beyond level 2. A version of Cohen's Kappa Table 7 Type of Continuity Warrant by Suicidal Status Type of Warrant Suicidal Status 0. None 1. Simple Inclusion 2. Typological 3. Essentialist 4. Functional High Risk (n=l3) 10 (77%) 0 (0%) 1 (8%) 0 (0%) 2 (15%) total 10 (77%) 1 (8%) 2 (15%) Low Risk (n»16) 1 (6%) 7 (44%) 6 (37%) 2 (13%) 0 (0%) total 1 (6%) 13 (81%) 2 (13%) Control (n=29) 0 (0%) 4 (14%) 7 (24%) 15 (52%) 3 (10%) total 0 (0%) 11 (38%) 18 (62%) N=58 (Cohen, 1960) was used to test the specific predicted one-to-one association described above between the suicidal status of these subjects and the categories of warrants they were found to employ as arrayed in Table 7 (rows = totals of combined levels of continuity warrants). A high level of category agreement was obtained (K = .71) which was significant at the preset level of .05. It should be noted that the level of agreement as represented by the Kappa statistic probably underestimates the "true" level of agreement to prediction given that the testing of observations along the diagonal does not take into account the normatively expected, and obtained, variation among the differentially aged high school subjects. Two further observations of note are apparent in Table 7. The first is that among the low risk adolescents who employed relatively immature continuity warrants (n=13) more than half made use of the most primitive of these claims (level 1 simple inclusion warrants) whereas only 4 of the 11 high school adolescents (36%) using the least mature warrants actually relied on level 1 justifications of personal continuity. Finally, it is of interest that two of the three high risk adolescents who did manage to evidence any understanding of how it is that one could be said to persist as the self-same person despite radical personal change, did so by employing warrants equal to those of the highest scoring non-hospitalized controls. Not only did these two adolescents fail to respond in the way anticipated, but the level of warrants which they employed set them quite apart from the rest of the high risk group. Conceptually, it would appear that these two subjects represent a separate subgroup of young persons at high risk for suicide. In order to justify such an assumption, a post hoc discordancy test for k upper outliers in a gamma (or exponential) sample was conducted and the results of this test (p_<.01) indicated that these two observations would be considered outliers on statistical grounds as well. All of the results detailed above were based on individuals' averaged scores across the three continuity measures. The high concordance rate among these three measures, and the fact that within-subject scores differed by no more than one adjacent category level, support the appropriateness of these summarial measures. There are, however, good reasons for going beyond such averaged scores and focusing attention upon the specific ways in which subjects warranted their own personal continuity across the changes that have occured in their own lives. The first, and perhaps most obvious, reason was that the self section of the continuity measure is most pertinent to the issue of interest here. From the outset, asking subjects about the continuities in the lives of third party characters was adopted primarily as a means of providing some guarantee that each subject would be confronted with at least some unarguable character changes and forced to search for grounds upon which to argue for personal continuity however ready they might be to deny or minimize such changes in themselves. Previous research had also indicated that having first addressed the question of continuity in the lives of these fictitous characters, subjects were less inclined to discount the important changes in their own lives. While the fact that most, but not all, subjects employed the same generic form of argumentation when seeking to warrant their own and other's continuity speaks against the need for any separate analysis, it still could be argued that the inclusion of questions about such third parties was largely procedural and that it is the self section of the continuity measure that should be of primary interest. On these grounds, separate analyses were conducted that featured only the self portion of the continuity procedure. Minor differences between the ways in which subjects argued their own and other's continuity did exist and investigating the possibility that these relatively small differences might be systematically related to their risk status seemed appropriate. Table 8 arrays the types of warrants employed by subjects in each of the three risk groups only on the self section of the continuity measure. As was the case with the averaged scores reported previously, there was a significant relation between risk status and these more direct measures of personal continuity (Kappa = .66, J3<.05). This result is not measurably different from that obtained with the averaged continuity scores (Kappa = .71, _p_<.05). As can be seen in Table 8, over half (7 of 13) of the high risk suicidal adolescents continued to be unable to offer any understandable means of justifying persistent identity, even when focusing on the details of their own lives. Another three, also generally at a loss, did manage to evoke an immature level 1 type of continuity warrant. Among the low risk hospitalized group, only one subject retreated from a level 2 to a level 1 continuity claim, whereas four of these adolescents were able to make use of some version of the more robust essentialistic arguments (level 3) when dealing with the issue of their own personal continuity. Similarly, four of the six high school adolescents whose scores shifted on the self portion of the interview showed an increase in the adequacy of their continuity warrants, abandoning level 2 claims in favour of level 3 essentialistic warrants. Two high school students did not complete the self section of the continuity measure due to time constraints and scheduling difficulties. Nascent Skeptical Doubt and Suicidal Risk The Nascent Skeptical Doubt Interview A Kruskal-Wallis one-way analysis of variance by ranks on the 57 subjects' averaged doubt scores by suicidal risk category indicated that there were significant differences between groups in the types of responses to emergent doubt ()C'{2):= 14.36, _p_<.0009). The highest mean rank was obtained by the high school participants (36.59) followed by the low risk T a b l e 8 Type o f C o n t i n u i t y W a r r a n t by S u i c i d a l S t a t u s S e l f O n l y T y p e o f W a r r a n t S u i c i d a l S t a t u s 0 . None 1 . S i m p l e I n c l u s i o n 2 . T y p o l o g i c a l 3 . E s s e n t i a l i s t 4 . F u n c t i o n a l H i g h R i s k (n=13) 7 (54%) 4 (31%) 0 (0%) 1 (8%) 1 (8%) t o t a l 7 (54%) 4 (31%) 2 (15%) Low R i s k (n*16) 1 (6%) 8 (50%) 1 (6%) 6 (38%) 0 (0%) t o t a l 1 (6%) 9 (56%) 6 (38%) C o n t r o l (n=27) 0 (0%) 5 (19%) 1 (4%) 19 (70%) 2 (7%) t o t a l 0 (0%) 6 (22%) 21 (78%) N=56 group (22.97) and the high risk group (18.71). Mann-Whitney U-tests further indicated that significant differences existed between the doubt scores for the high school group as compared with those for the low risk suicidal adolescents (z_=-2.63, _p_<.009), but that the scores for the low risk and high risk adolescents did not significantly differ (z==-0.65, _p_>.51). Table 9 displays the types of responses employed by each of the three subject groups. For the purposes of this table and all further analyses, individuals who scored at "transitional" levels were credited with their best efforts and categorized into the higher of the two levels. Two observations of note are immediately apparent upon a review of Table 9. First, not one of the suicidal adolescents (high or low risk) made use of post-skeptical rational solutions in contrast to 28% (8 of 29) of their high school peers who employed such level 3 strategies. Second, it is clear that among the hospitalized adolescents only a few gave evidence of appreciating the relativized character of the knowing process. In fact, only a single high risk subject reasoned at a level beyond a level 1 (defended realism) strategy. Low risk suicidal adolescents showed a similar, though less dramatic, pattern with 69% (11 of 16) still employing level 1 (defended realism) strategies. \ In order to assess the hypothesis which predicted a specific association between suicidal behaviour and a posture of defended realism, a 2-by-2 contingency table was constructed. For this purpose, responses scored at level 1 (defended realism) were contrasted with responses scored at either level 2 (dogmatism-skepticism axis) or level 3 (post-skeptical rationalism) solutions and then arrayed against risk status. Based upon the previously reported Mann-Whitney U-test which indicated that the high and low risk groups were not significantly different, these two groups were combined to form a single hospitalized group of varying suicidal levels and contrasted with the high school control group. Table 10 Table 9 Responses to Nascent Skeptical Doubt by Suicidal Status Type of Strategy Suicidal Status Defended Realism Dogmatism-Skepticism Post-Skeptical Rationalism High Risk (n=12) 11 (92%) 1 (8%) Low Risk (n=16) 11 (69%) 5 (31%) Control (n»29) 7 (24%) 14 (48%) 8 (28%) N»57 Table 10 Responses to Nascent Skeptical Doubt Suicidal vs. Non-Suicidal Type of Strategy Suicidal Status 1. Defended Realism 2. Dogmatic/Skeptical 3. Rational Hospitalized (high & low risk) 22 (79%) 6 (21%) Non-Hospitalized (high school controls) 7 (24%) 22 (76%) M=57 (1)=14.781, B<.0002 illustrates this 2-by-2 array. A Chi-Square test of association indicated that the two groups were significantly different in their responses to the prospect of emergent doubt CXt(D= 14.78, _p_<.0002) with almost 80% of the suicidal adolescents relying on level 1 defended realism strategies as opposed to just under 25% of their age-matched high school peers. Of the six hospitalized adolescents who did make use of dogmatic/skeptical strategies, two were male and four were female. This ratio conforms to the general male female ratio of the sample (1:1.9). Interestingly, and in contrast to the normative sample, the use of higher level 2 strategies did not appear to be related to age in the hospitalized group with six of the high scorers occuring among 13-year-olds, two among the 14-year-olds, and only one from each of the 16- and 17-year-old groups. The Nascent Skeptical Doubt Questionnaire Averaged questionnaire scores were available for 53 of the adolescents otherwise tested. Two of the hospitalized volunteers and three of the high school students did not complete this questionnaire. All but four of the questionnaire respondents made use of the entire scale range (0-3) in their responses. The averaged scores were based on the original responses recoded according to the relativism key so that low scores were characterized by realistic views and high scores by more relativized views regarding the possibility of certain knowledge. On the rationale that the questionnaire was meant to serve as an adjunct measure to the Nascent Skeptical Doubt Interview procedure, the first investigative step taken was to assess the relation between these two doubt measures. Since there were no preset cut off scores by which to categorize individuals for comparison purposes according to their averaged score on the doubt questionnaire, subjects were divided on a proportional basis to match the proportion of subjects coded at either level 1 (defended realism) or levels 2 and 3 (dogmatic/skeptical and rational) by the interview procedure. No distinction was made between levels 2 and 3 since the questionnaire was not designed to discriminate between these alternative strategies for dealing with recognized generic doubt. Of the 53 subjects for whom scores on both of the doubt measures were available, 27 had been coded at level 1 and 26 coded at levels 2 or 3 on the basis of their interview responses. In symmetry, then, the 27 lowest scoring (most realistic) and the 26 highest scoring (most relativized) individuals on the doubt questionnaire were grouped to form two comparative categories. The resulting 2-by-2 contingency table in displayed in Table. 11. The two doubt measures were found to be highly associated as evaluated by a Chi-Square test (%l(l) = 9.97, _p_<.002). Almost 75% of individuals coded at level 1 on the doubt interview also scored in the lower portion of the questionnaire responses as defined by the present overall sample. Similarly, approximately 75% of level 2 and 3 subjects scored in the higher portion of the questionnaire responses. The second step taken in an effort to evaluate the usefulness of the doubt questionnaire was to assess directly whether subjects' responses to this measure were related to their suicidal status in a consistent and interpretable manner. A one-way analysis of variance on the averaged scores by suicidal risk category indicated significant group differences in the overall scores across the 20-item questionnaire (F(2,50) = 13.37, _p_<.0001). Suicidal adolescents in the high risk category were found to score significantly lower (toward the realistic end of the scale) than either the low risk or control groups as assessed by the Student Newman-Keuls method at the .05 level of significance. The Newman-Keuls further indicated significant differences between the low risk suicidal group and the high school controls {o<- =.05). The highest group mean of the averaged scores was obtained by the high school students (X=1.92, SD = .25), Table 11 Scores on the Doubt Questionnaire Proportionally Dichotomized by Doubt Interview Responses Doubt Questionnaire Scores (Dichotomized) Response to Doubt Interview Lower (absolutistic) Higher (rela t i v i s t i c 1. Defended Realism 20 (74%) 7 (26%) 2. Dogmatic/Skeptical 3. Rational 7 (27%) 19 (73%) ( D - 9 . 9 7 , B<.002 M=53 followed by the low risk adolescents (X=1.73, SD = .31), and the high risk adolescents (X=1.43, SD = .29). The overall mean across all subjects on the questionnaire was 1.75 (SD = .33) with scores ranging from .95 to 2.35. Table 12 illustrates the distribution of individuals categorized by suicidal risk who scored in either the lower or higher range of scores on the questionnaire. The questionnaire scores were again divided on a proportional basis as matched to the doubt interview responses. The actual cut-off score was 1.75 which was identical to the overall mean averaged score on the questionnaire. As can be seen from Table 12 almost all of the individuals at high risk to suicide (92%) showed close agreement with statements espousing absolutistic views, and less agreement with more relativized views across a wide variety of domains. In contrast, almost 70% of the high school students favoured the more relativized response alternatives. Low risk suicidal adolescents were almost evenly split between the lower (53%) and higher (47%) scoring portions of the doubt questionnaire. SUMMARY OF RESULTS As predicted, hospitalized adolescents at low risk for suicide were found to employ less mature warrants of personal continuity than did their high school age mates, while those subjects at high risk for suicide were generally found to be at a complete loss as to how to justify the conclusion of their own or others' persistent identity across time. The same pattern of results emerged whether analyses were based upon subjects' averaged continuity scores across the three warranting opportunities, or their self scores alone. A small subset of the high risk adolescents (2 of 13) whose responses did not conform to this general pattern were found to make use of the most mature of the warranting Table 12 Scores on the Doubt Questionnaire (Proportionally Dichotomized) by Suicidal Status Doubt Questionnaire Scores (Dichotomized) Suicidal Status Lower (absolutistic) Higher (rela t i v i s t i c High Risk (n=12) 11 (92%) 1 (8%) Low Risk (n-15) 8 (53%) 7 (47%) Control (n»26) 8 (31%) 18 (69%) (2)«12.23, B<.003 N=53 strategies employed by their high school peers. These two subjects were considered outliers on statistical as well as conceptual grounds. Both low and high risk suicidal adolescents were far more likely to employ immature level 1 strategies (defended realism) in response to matters of uncertainty and doubt than were their high school age mates who, by contrast, were found to make use of increasingly more mature strategies for coping with such uncertainties with increasing chronological age. Analyses of responses to the doubt questionnaire indicated that high risk subjects agreed most strongly with absolutistic views while the high school subjects were most in agreement with more relativized statements. Low risk' suicidal subjects' responses fell between these two groups with the mean score of the low risk group being somewhat closer to that of the high risk group versus the high school controls. The approach taken throughout this results section has been to assess the relations between suicidal status and responses to the continuity and doubt measures separately with little attention given to how these measures may convergently relate to degree of suicidal risk. While this approach has been adequate to test the specific. hypotheses of this study and perhaps most appropriate given the categorical treatment of most of the data, some means of viewing the data in an overall, collective manner would provide a more integrative picture than has so far been possible. With this goal in mind, a multiple discriminant function analysis was conducted with high risk, low risk, and control groups representing the three categories of the criterion variable and the continuity and the two doubt measures as the three predictor variables. For the purposes of this analysis, the original, noncollapsed scores from the continuity and doubt interviews were used and treated as continuous interval data. The first step in this multiple discriminant function analysis was to determine whether the three predictor variables could, as a set, discriminate between the criterion groups. The Wilks' lambda statistic was calculated to be .415, which is equivalent to an F-ratio (6,96) of 8.84 (p_<.0001), indicating that the predictor variables did discriminate among the groups. Table 13 displays the standardized canonical coefficients and pooled within-group correlations for each of the three variables. Subjects' averaged continuity scores and scores on the doubt questionnaire were the two most discriminating variables followed by the more global epistemic level scores. Overall, 75.86% of grouped cases were correctly classified. The classification summary table, also displayed in Table 13, indicated that the predictor vaiables were most accurate in classifying the high risk adolescents (84.6% correctly classified) and the control subjects (86.2% correctly classified) whereas among the low risk group only 50% were classified correctly. It is of note that none of the control subjects was misclassified as a high risk subject and only one (7.7%) of the high risk adolescents was misclassified as a member of the control group. The incorrectly classified low risk subjects were evenly divided among high risk (25%) and control (25%) subjects. Overall, performance on the continuity and doubt measures clearly differentiated high risk suicidal adolescents from their high school peers. Discrimination was less accurate for the low risk suicidal subjects. It seems that the pattern of responses by some of the low risk group resembled those of their high risk peers, while others responded much like the high school controls. The results of this discriminant function analysis need to be interpreted with some caution on several accounts. First, the accuracy in group classification may be somewhat optimistic since the performance criteria for group membership used in the analysis was derived from the performances of the same subjects who were then placed into the various Table 13 Discriminant Function Analyses Classifying Suicidal Risk Standardized Canonical Pooled Within-Group Coefficients Variable Correlation .674 Continuity .66 .628 Doubt Questionnaire .63 .332 Doubt Interview .50 Classification Summary Table Predicted Group Membership Actual Group n Control Low Risk High Risk Control 29 25 4 (86.2%) (13.8%) Low Risk 16 4 8 4 (25%) (50%) (25%) High Risk 13 1 1 11 (7.7%) (7.7%) (84.6%) Grouped Cases Correctly Classified: 75.86% groups. While proceeding in this manner is common practice, it does bias the results in favour of group membership prediction accuracy (Huck, Cormier, & Bounds, 1974). Second, the prediction of group membership on the basis of performance on these three variables should not be interpreted as suggesting any strict correspondance between measure scores and suicidal status. That is, the developmental nature of the measures used must be taken into account. One means to accomplish this would be to enter a preset performance criteria for group membership which incorporated the age-graded appropriateness of various response levels. In addition, it would be helpful to approximate a match between the number of subjects in each of the suicidal risk categories and the estimated proportion of like individuals in the local population. ( C H A P T E R 4: DISCUSSION The general aim that guided this study was to make some contribution to the emerging field of developmental psychopathology through an examination of the relations between progressive movement toward social-cognitive maturity and socioemotional adjustment in adolescence. More specifically, the two developmental matters of particular concern were the contrastive ways in which suicidal and nonsuicidal adolescents undertake to secure a sense of their own personal continuity and a sense of conviction in the face of growing skeptical doubts. In order to explore these possible relations, a comparative analysis was undertaken which set in contrast a group of psychiatrically hospitalized adolescents and a matched sample of their high school peers. The central hypothesis tested in this study was that the self-destructive tendencies of the suicidal subjects could be understood as behavioural manifestations of difficulties in dealing with matters of emergent skeptical doubt and personal continuity. The results of this study clearly demonstrate that, in comparison to their nonhospitalized age mates, the psychiatrically hospitalized suicidal adolescents did evidence difficulties both in their abilities to understand how they and others could be said to remain continuous or self-same persons throughout time, and in their ability to cope with questions of uncertainty and doubt. Adolescents at high risk for suicide were distinguished from other psychiatrically hospitalized individuals at low risk to suicide and from their high school age mates by: 1) their unique inability to find any workable means of justifying their persistent identity; and 2) by their more extreme endorsement of absolutistic views in the face of uncertainty. In addition to these contrastive results, the data generated by the normative sample were found to closely conform to that of previous studies, further documenting the ways in which individuals at different developmental stations both warrant personal continuity across time (Chandler et al., 1987) and respond to issues of uncertainty and doubt (Boyes, 1987). The details and implications of these findings will be discussed in the paragraphs that follow. Details and Implications of the Research Findings Theoretical Implications Several important theoretical implications follow from the results of this study. First, the replication of the normative data lends additional support to the following claims: 1) that the use of alternative solution strategies to the problems of numerical identity and nascent skeptical doubt can be reliably and exhaustively identified in accordance with the typologies laid out in the introduction; 2) that individuals respond to questions concerning these two important developmental issues in a consistent manner across multiple testing response opportunities; and 3) that progressively more adequate and mature responses are associated with increasing chronological age. Together these findings strongly suggest that the manner by which individuals warrant personal continuity, and contend with matters of doubt both follow an age-graded developmental sequence leading to increasingly more adequate and mature levels of responses. Secondty, the results of the comparative analyses between the normative sample and the high and low risk suicidal adolescents suggest that important dimensions of developmental difference exist between these groups. The nonhospitalized control subjects tested in the present study were found to respond to the issues of continuity and doubt in ways typical of others of the same approximate age, grade, and social status (Boyes, 1987; Chandler et al., 1987). By contrast, the hospitalized subjects, all of whom were to some extent suicidal, were found to lag behind their age-matched peers, and, as a group, consistently scored at lower, less developmentally mature levels on measures of numerical identity and doubt. These findings, while still correlational, lend support to the general theoretical attempt of this thesis to interpret certain socioemotional difficulties experienced by adolescents as arising from a developmental asynchrony between their progressive movement toward more abstract, relativized, and self-reflective modes of thought and the task of securing more mature strategies for dealing with the reconceptualizations of the problems of continuity and doubt which these cognitive advances necessitate. Third, the fact that young persons considered to be at high risk for suicide were generally distinguished from their psychiatrically hospitalized and nonhospitalized peers by their unique inability to voice any sort of justification of personal continuity across time suggests the possibility of interpreting such serious suicidal tendencies as behavioural manifestations of the complete loss of a sense of persistent identity. This finding underscores both the importance of achieving a sense of personal continuity to the adolescent identity formation process, and emphasizes the central role which the achievement of such a sense of numerical identity plays in the emotional lives of adolescents. In addition, these results go some distance toward explaining the sudden and dramatic increase in suicidal behaviour that characterizes the adolescent years. If, as numerous theorists have suggested, achieving a sense of personal continuity is essential to the identity formation process, and if, as findings reported here indicate, adolescents who fail in this developmental task also tend to be those who make serious attempts on their own lives, then the prospect is opened up for explaining the high incidence of attempted suicides in this age group. It is also of theoretical importance to note that not all of the high risk suicidal adolescents evidenced difficulties in warranting personal continuity over time. In fact, two of these high risk subjects made use of continuity warrants as adequate as those of the most mature subjects of the normative sample. This finding indicates the existence of a small subset of seriously suicidal young persons whose difficulties must reside in some radically different quarter. While speculation as to the source of these other difficulties is clearly beyond the scope of this thesis, the caution which their presence suggest needs to be stressed. There are obviously other ways for an adolescent to lose faith in the promise of his or her own future and continuity problems can not and should not be interpreted as providing a simple and sovereign solution to the interpretation of these difficulties. Fourth, results based on the Nascent Skeptical Doubt Interview support the view that dogmatic and skeptical responses to matters of uncertainty represent reasonably adaptive responses to issues of doubt, at least during adolescence, or until the need to make life commitments becomes more pressing. Only one (of 12) high risk suicidal subject showed any evidence of having achieved such a skeptical or dogmatic solution for dealing with doubt. By contrast, almost one third of the low risk group and approximately one half of the normative sample did so. The fact that none of the hospitalized subjects evidenced a post-skeptical (level 3) position, whereas approximately one quarter of the high school sample did so also is consistent with the argument presented in this thesis that such rational strategies represent a more adequate means for proceeding with commitment in an uncertain world. This interpretation is further supported by the results of the doubt questionnaire which located respondents along an objectivism-relativism dimension. By this measure, high risk subjects were most in agreement with objectivist views, high school subjects expressed the most agreement with relativistic views, and low risk subjects appeared to fall somewhere between, though their responses were closer to those of their high risk peers. Finally, the implications of the negative results obtained from the use of the Hopelessness Scale need to be mentioned. The most obvious conclusion to draw from the negative and statistically nonsignificant correlation obtained between individuals' assessed level of suicide risk and their degree of hopelessness as measured by Beck's scale is that the Hopelessness Scale is not an appropriate measure for the assessment of suicide risk in adolescents. Given that the scale was derived for the purpose of assessing clinical populations, it cannot be argued that the hospitalization of these subjects per se contributed to the ineffectiveness of this measure. It could, however, be argued that once in the hospital setting, the initiation and/or promise of therapeutic assistance encouraged an optomistic outlook on the part of these troubled individuals. This is a problematic explanation for the following reasons: 1) the Adolescent Unit from which the hospitalized subjects were drawn is primarily an assessment rather than a treatment facility; 2) the ratings of suicide risk were based on information contained in individuals' hospital records and discharge summaries and high risk ratings were dependent upon evidence of a continuing and substantial degree of concern over the possibility of suicide; and 3) no association was found between the length of time (in days) in hospital prior to testing and scores on the Hopelessness Scale (rho = .09, _p_>.32). In addition, the conceptual association between an overwhelming sense of hopelessness and unadulterated skepticism, combined with the results of the doubt interview indicating that an epistemic posture of skepticism did not characterize these troubled youths further suggests that, whatever its merits when applied to an adult population, the Hopelessness Scale is not a sensitive measure for the assessment of suicide risk in adolescents. Diagnostic and Treatment Implications The most important diagnostic implication of the results of this study is that hospitalized adolescents who are unable to maintain a sense of persistent identity across time should be regarded as being at high risk to suicide. Conversely, however, it is not safe to conclude that young persons who do not appear to be suffering such a loss of identity are necessarily free of the risk of suicide. In other words, the present data suggest that the assessed inability to warrant personal continuity implies the likelihood of serious suicidal tendencies, but it is not an exclusive route to such suicidal behaviours. Still, given the difficulty of identifying persons who pose a serious suicide risk, procedures for assessing personal continuity promise to provide a valuable diagnostic tool for identifying persons in this risk group. In addition to the possibility of identifying individuals who are highly suicidal, the findings of this study suggest that, in the process, such identification may also be discriminating a particular subgroup of suicidal individuals who share a certain "suicidal syndrome", different from those identified above. If, as it appears from the results of this study, a substantial number of seriously suicidal adolescents lack the ability to understand how they can change over time without losing their identity, this fact further suggests a set of reasons as to why such individuals might be especially resistant to therapeutic change. That is, persons who have not yet achieved an adequate means of counting themselves as numerically identical are likely to be slow to participate in any treatment process aimed at changing them in radical ways. This negative implication is tempered, however, with the positive therapeutic potential imbedded in the identification of developmentally appropriate warrants of continuity routinely employed by typical adolescents. The normative developmental course of understanding personal continuity provides both a standard and a possible goal for such intervention. Furthermore, the fact that almost all of the high risk (92%) and a majority of the low risk (69%) subjects held to positions of defended realism suggests that, for such individuals, therapeutic interventions aimed at elucidating alternative courses of action are also likely to be met with frustration and rejection. That is, for such adolescents, steeped in a world view that understands different interpretations of reality as the product of vested interests, all attempts to encourage such alternative views are likely to be treated with suspicion. This result partially echoes findings reported by Shneidman (1985), who stresses that suicidal persons are especially prone to a kind of dichotomous thinking that allows only one solution to every problem. As previously discussed in the introduction, a number of cognitively oriented researchers have identified an association between suicidal behaviour and rigid, dichotomous thinking (Arffa, 1983; Beck et al., 1984;. Faberow, 1985; Neuringer, 1961, 1964, 1967; Neuringer & Lettieri, 1982; Patsiokas et al., 1979; Shneidman, 1985). While consistent with these findings, the cognitive-developmental account presented in this thesis offers an interpretation that 1) distinguishes two very distinct modes of thinking, both of which display components of rigidity; 2) describes how these two different epistemic positions would be differently manifested; 3) situates each along a developmental trajectory; and, by doing so both 4) makes more comprehensible the high incidence of suicidal behaviour in this period; and 5) provides therapeutically relevant age-graded developmental standards for evaluating strategies in dealing with issues of uncertainty and doubt. Of course, the diagnostic and therapeutic implications extrapolated from the present study must be considered highly speculative and in need of investigation in their own right. In addition, the relevance of the obtained results need to be viewed in light of the shortcomings and limitations of this particular study detailed below. Limitations and Suggestions for Future Research Although the findings of the present study indicate clear differences between the groups tested, the small sample sizes make these results rather tentative. This is particularly true in regard to distinctions among the psychiatrically hospitalized adolescents who were subdivided into high and low suicidal risk groups. Greater confidence could be placed in results obtained if they were confirmed by the testing of a larger sample of both high and low risk suicidal adolescents. A second issue pertaining to the generalizability of these results concerns the choice of appropriate control groups. What has been demonstrated here is that within a sample of psychiatrically hospitalized adolescents, all of whom were to some degree suicidal, those at high risk to suicide evidenced unique difficulties in dealing with certain developmental matters as compared with their low risk suicidal counterparts and a matched sample of normal controls. It is not clear, however, how a matched sample of equally troubled but nonsuicidal young persons would respond to the measures. The arguments presented in this thesis would lead to the prediction that all nonsuicidal psychiatric controls would score somewhere between the performances of the normal subjects and the low risk suicidal group. It is possible, however, that a more broadly representative psychiatric control group would subdivide along some other important dimension of difference and that a portion of such individuals would respond in ways more similar to the high risk subjects in this study. If this were the case, then the failures of the high risk subjects, while still having important implications for understanding and dealing with seriously suicidal young persons, would not represent such a unique hallmark of adolescent suicidal behaviour. The fact that almost all of the hospitalized adolescents tested were found to have caused some level of concern regarding the possibility of their being suicidal also raises the question of how representative these troubled youth were of a larger population of psychiatrically troubled adolescents. It may be the case that at least some degree of suicidal ideation tends to accompany almost all of the problems likely to result in young persons being placed in a closed psychiatric setting. It is also possible that some sort of identified risk to suicide was a tacit part of the selection criteria employed by the particular facility from which the subjects for this study were drawn. A sensible extension of the present work, then, would involve an attempt to establish whether a non-suicidal adolescent psychiatric population could be identified and subsequently used as a control group. Failing the identification of such a group, a second option might be to include a group of nonpsychiatric, but still problematic young persons of the sort that might exist in a sample of adolescents institutionalized for reasons associated with antisocial or delinquent behaviours. While it would be reasonable to assume that at least some of these individuals would have prompted concerns over the possibility of their suicide, it also seems reasonable to assume that a substantial proportion of such young persons would be relatively free of suicidal risk. Another important issue which needs to be addressed revolves around the interpretation of the scores on the continuity measure. The high risk suicidal subjects who were found to be at a complete loss as to how to warrant personal continuity over time essentially scored off the scale of hierarcharized levels of such continuity warrants. The question that this raises is whether such responses should be interpreted as failures to warrant persistent identity, or failures to respond to the continuity task. That is, there is the possibility that such failures represent individuals' unwillingness or inability to be responsive to the test-taking situation itself. While this possibility needs to be kept in mind, the responses of the high risk group have been interpreted here as actual failures to conserve identity across time. The reasons for this interpretation stem from the facts that: 1) each subject was presented with several different measures all of which were administered during the same interview session yet it was only on the continuity measure that such "off scale" results were apparent; 2) 74% (20 of 27) of responses in the failed scoring category involved initial attempts at justifying personal continuity which were subsequently discounted as inadequate by the subjects themselves; and 3) although the length of the continuity interview varied widely across subjects, it was not the case that those who had less to say were necessarily those who scored at the lowest levels of continuity warrants. In addition to increasing the sample sizes and incorporating a control group of nonsuicidal but troubled adolescents, the findings of this study suggest several directions in which future research could be fruitfully taken. 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J., & Griffin, N. J. (1983). Adolescents' concepts of depression among their peers. Adolescence, 18, 965-973. Smetana, J. (1983). Social-cognitive development: Domain distinctions and coordinations. Developmental Review, _3, 131-147. Smetana, J. (1985, April). Family rules, conventions, and adolescent-parent  conflict. Paper presented at the biennial meeting of the Society for Research in Child Development, Toronto. Syer, D. S. (1981). Suicide in Canada. Crisis-,- _2, 73-76. Taylor, S. (1978). The confrontation with death and the renewal of life. Suicide and Life-Threatening Behaviour, _8_, 89-98. Taylor, S. (1982). The study of suicide. London: MacMillan. Termansen, P. E. (1972). Suicide and attempted suicide in Vancouver. British Columbia Medical Journal , 14, 43-47. Treiman, D. J. (1977). Occupational prestige in comparative perspective. New York: Academic Press. Turiel, E. (1983). The development of social knowledge. New York: Cambridge University Press. Wexler, L., Weissman, M. & Kasl, S. (1978). Suicide attempts 1970-1975: Updating a United States study and comparisons with international trends. British Journal of Psychiatry, 132, 180-185. 88 APPENDICES Appendix A Numerical Identity Interview Procedure Now that you have read the story of Ebenezer Scrooge/Jean Valjean, I'd like to ask you some questions about him. 1. First of all, tell me what Scrooge was like at the beginning of the story. 2. What was Scrooge like at the end of the story? 3. How else might you describe Scrooge at the beginning and at the end of the story? 4. In summary, then, how would you say that he has changed from the beginning to the end of the story? 5. You have now told me a lot of ways that Scrooge has changed from the beginning to the end of the story. You've told me (how he's gone from being mean and stingy to being kind and generous) (how he used to have no friends and now he has lots of friends and everyone likes him). So it seems that Scrooge has changed alot and in some pretty important ways, yet we know, even though he seems so different, that the person described at the beginning and at the end of the story are both the same person. Does that seem right to you? 6. Given all the changes and the ways in which he seems so different, what is it that makes Scrooge one and the same person throughout the story? 7. (Assuming only a list of similarities is offered) You are right - those are things which are the same at the beginning and at the end of the story. Are there other ways in which we can understand Scrooge to be one and the same person throughout the story, despite all the changes that you have mentioned? 8. What if Scrooge (did change his name) (did move to another house), would that make him another person? What is it, then, that makes him the same person? 9. What about Scrooge himself - does Scrooge think he is the same person? That is, when Scrooge in the end remembers Scrooge in the beginning, does he think that those things that happened then actually happened to him? 10. How might Scrooge explain to someone else that one and the same person could act in all the different ways that he acted througout the story? We have been discussing changes in the lives of two story characters -Jean Valjean and Ebenezer Scrooge - and my questions have been about how these characters can be understood to be the self-same persons despite the fact that they went through a number of important changes in the course of their stories. Now I want to ask some similar questions about you and your life. 1. First, I would like you to describe what you were like about five years ago, when you were (10). 2. How would you describe yourself now? 3. So, in what important ways do you think you have changed from when you were (10) to the (15) year old you that you are now? 4. You've told me some important ways in which you have changed since you were (10). In addition, there are probably other things that you could list which have changed such as (the way you look) (what you like to do) (some of your attitudes and beliefs). Are there things like this that you could name that you feel have changed? 5. Okay. You have told me a lot of important changes that you feel have taken place in your life and that have happened to you. In all the ways that you have mentioned, you are now very different than you were five years ago. Still, like Valjean and Scrooge, the story you have told me about your life is a story about one person. What I now want you to explain is why you think you are the self-same person that you were five years ago. What makes you the same person? If you (didn't still live in the same house) would that make you a different person? What is it, then, that makes you one and the same person even though you have changed in all these important ways? How is it that you can still consider yourself one and the same person? How would you answer someone who pointed to all of the changes in your life and claimed that it would be better to think of the person you are now and the person you were five years ago as two completely different people? Think about your best friend and all the ways that you and s/he are alike. In many ways you are probably more like your best friend right now than you are like the person you were five years ago. Wh}' do you say that you are still the same person, but that your friend is a different person? Appendix B Nascent Skeptical Doubt Stories and Interview Procedure Driving Age In a small town in British Columbia a meeting had been called about whether the local high school should continue to offer a driver's education course. Many parents were against the school offering this course and many students wanted the course to continue. A committee of parents and a students' committee both wrote articles which appeared in the local paper before the meeting took place. Parts of these articles are shown below. Report by The Parents' Committee for Safe Driving We are opposed to the high school offering a driving training course for its students. Scientific information presented in this paper over the past few weeks clearly shows that 16-year-olds, as a group, are not responsible enough to be trusted with the handling of a motor vehicle. While the law now permits 16-year-olds to obtain a driver's license, with parental permission, teenagers should not be allowed to drive until they are at least 19 years old. Offering a driver training course through the school puts unfair pressure on parents to let their children learn to drive before they are 19-years-old. The course must be taken out of the school immediately for the safety of all concerned. Report by The Students' Committee for Young Drivers We are in favour of continuing the driver training course in our high school. The scientific information that has been printed in this newspaper and elsewhere support the view that 16-year-olds are just as responsible as adults and should be able to learn to drive as soon as they are legally allowed to do so. The driver training course in the high school encourages students to follow a proper training program and become better drivers. The law allows us to drive at 16 years of age and we should have a training course in our school for everyone to take. Native Lifestyles Recently, sociologists who have spoken to West Coast Indians and studied their society, published two new books about the West. Coast Indians and their relation to our non-native society. What follows are paragraphs from the first page of each of these new books. Cultural Independence and the Coastal Indians We have interviewed, lived with, and studied the West Coast Indians, and their culture, and have found that they led happier, richer, more meaningful lives when they lived on their own, in tribal groups, than they did after they had contact with Europeans and others who settled North America. Even though modern influences have improved a few things overall, however, contact with non-native people since pioneer times has brought the Coastal Indians many problems. These problems are so serious that the best thing that could happen would be for native people to become more independent of non-native groups. West Coast Indians: A Case for Cultural Integration Based on a large research project in which we lived with and interviewed West Coast Indians, and studied their culture, we found that their lifestyle today is happier and more prosperous than it ever was. Modern knowledge in such areas as health care and education, and modern technology in the fishing industry and other areas, has greatly increased the standard of living, financial security, and happiness of the West Coast Indians. Even though a few problems have been created in the course of the many changes that have taken place as a result of contact with the non-native society, overall the benefits far outweigh these temporary adjustment issues. The best thing that could happen would be for native people to increase their contact with the non-native population. Now that you have read the reports by the parents' and the students' committees/ the two sociologists, I'd like to ask you some questions about them. 1. First of all, on the basis of what you've read, tell me what the parents' and students' committees said about the issue of 16-year-olds being responsible enough to drive. 2. Are the arguments and conclusions of the two committees different in any important ways? How are they different? 3. How could these two committees end up having such different things to say about the issue of 16-year-olds being responsible enough to drive? 4. Why do you think these two committees wrote such different articles? 5. Do you think that one of the committees has got the facts wrong? How important is that to the disagreement? (Would that be important to the disagreement?) 6. If these two groups had all of the very same information, might they still disagree? How is that possible? (Why is that not possible?) 7. It sounds as though you're saying that people can view things in any way that they want. Is that what you are saying? 8. What if another group reviewed the same information and decided that kids should be allowed to drive when they were 12-years-old, would that be an okay opinion to have? Why (or why not)? 9. What if a group of specialists reviewed the positions of the parent and student committees. Do you think that the specialists might know what was best to do? What makes you say that? 10. Is there a way of deciding which of these reports the principal should pay the most attention to in deciding the fate of the driver training course? Could you explain why you think that? 11. What sorts of things should the principal consider in order to 96 determine what best to do about the driver education course? General Section 1. What is it about these situations that makes finding out or deciding what is right or best so hard? 2. Is that true just for these situations or is it generally true? That is, are these just wierd situations, or are there a lot of situations like these in life and in the world? 3. How should we approach these sorts of situations, what should we do? How should we decide what to believe and what to do? 4. We could just decide to go our own ways when we disagree but, as in these situations, we often cannot do that. What then shall we do? How do we decide what to think in these sorts of situations? Appendix C Nascent Skeptical Doubt Questionnaire This questionnaire consists of 20 statements. Please read each statement and rate it in terms of how similar it is to your own views. Using the following rating scale, CIRCLE the number that best represents how close that view is to your own. Similarity Rating Scale: 0 = very dissimilar 1 = somewhat dissimilar 2 = somewhat similar 3 = very similar 1. When I hear that some experts think parents should be very permissive with their children, and that others think they should be very strict, I think that both these views amount to little more than preferences for one style of raising children over another, and neither one can be said to be better than the other. How similar: 0 1 2 3 -circle one 2. Over the ages, different countries have had, and many people have preferred, very different forms of government. I would say that if people were more aware of what was in their best interests, they would be able to see which form of government is the best. How similar: 0 1 2 3 -circle one 3. When it comes to interpreting dreams, I think that some people seem to be able to decide what a dream really means. How similar: 0 1 2 3 -circle one 4. For everj' piece of art, there are always some people who think it is good, and others who do not. This suggests to me that all claims about good and bad art are nothing more than expressions of personal taste. • How similar: 0 1 2 3 -circle one 5. When I read reviews of movies in the newspaper, I think that movie critics simply give their own opinions, which are really no better or worse than anyone else's. How similar: 0 1 2 3 -circle one 6. Some people think that the universe was created suddenly, and others think it came into being over a long period of time. It seems that one of these theories must necessarily be wrong. How similar: 0 1 2 3 -circle one 7. The fact that the same bible passages are often interpreted in very different ways suggests to me that biblical texts are often written in such a way that you can find almost any meaning in them you want. How similar: 0 1 2 3 -circle one 8. Most of the basic uncertainties of modern life could be eliminated if people would only make greater efforts to pay careful attention to the facts. How similar: 0 1 2 3 -circle one 9. Some experts claim that you inherit your intelligence from your parents, while others think intelligence depends on the experiences one has. It seems to me that both these views amount to little more than hunches, because you can view intelligence in almost any way you want. How similar: 0 1 2 3 -circle one 10. Wine experts argue over which vineyards produce the finest wines. I would say that if one made a careful study of wines, it would eventually become apparent which vineyards produced the finest wines. How similar: 0 1 2 3 -circle one 11. Different sportscasters sometimes make very different claims about what a particular athlete is like. From this I conclude that what really distinguishes good from bad sportscasters is the degree to which they stick to the facts. How similar: 0 1 2 3 -circle one 12. When it comes to interpreting dreams, I think that nobody has any way of knowing what a dream might really mean, and so you might as well believe whatever you like. How similar: 0 1 2 3 -circle one 13. Truth amounts to nothing more than a word people use to make their own view seem more respectable. How similar: 0 1 2 3 -circle one 14. When I hear that some experts think parents should be very permissive with their children, and that others think they should be very strict, I think that with a little more effort, the experts who study such things could determine which of these is the best way to go about raising children. How similar: 0 1 2 3 -circle one 15. Some people think that the universe was creeated Suddenly, and others think it came into being over a long period of time. It seems that we'll never know what happened millions of years ago, so most people should believe whatever suits them. How similar: 0 1 2 3 -circle one 16. Behaviours which are thought to be wrong in one country are often judged to be right by other groups. This tells me that some of these groups are obviously confused about what right and wrong really mean. How similar: 0 1 2 3 -circle one 17. For every piece of art there are always some people who think it is good art and others who do not. This suggests to me that while some people are able to judge artwork accurately, other people can't tell good art from bad. How similar: 0 1 2 3 -circle one 18. Wine experts argue over which vineyards produce the finest wines. I would say that these arguments will probably continue because people have no good grounds for determining which wines are best. How similar: 0 1 2 3 -circle one 19. There are many changes in musical preferences from one generation to the next. This suggests to me that some generations tend to reject good music and are attracted instead to music which has no real quality. How similar: 0 1 2 3 -circle one 20. Most of the basic uncertainties of modern life will always be with us, so for many important decisions the choices we make are no more than guesses. How similar: 0 1 2 3 -circle one Appendix D Suicidal Risk Rating Scale Level 1. No real concern over the possibility of suicide is expressed by others. There may be some talk of suicide on the part of the patient but this talk appears to be the product of psychosis or has occured in the distant past. Level 2. Suicidal talk is present on the part of the patient. The patient may have taken some mild (ie. low lethality) action but given the circumstances of the action(s) they were considered by others to be primarily hystrionic and/or manipulative. Level 3. Real concern over the possibility of suicide is expressed by others. Patient may or may not have acted but threats are believed and any actions taken appear to have been carried out in all seriousness. Level 4. Patient talks and demonstrates serious suicide intent. At least one serious life-threatening attempt has been made and there continues to be a high level of concern over the possibility of suicide expressed by others. 


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