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THE TURNING HOUR PROJECT: USING LITERATURE FOR SUICIDE EDUCATION IN
PATRICIA MARIA XIRAU-PROBERT
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
2007 Patricia Maria Xirau-Probert
To my husband, Jim,
with love and appreciation
I would like to thank Dr. Silvia Echevarria Rafuls Doan, the chair of my committee, for
providing ongoing support and encouragement throughout the (lengthy and trying) duration of
this study. Her knowledge and caring were truly appreciated. Te lo agradesco con el alma. I
am also grateful to Dr. Ellen Amatea, for her unending support and enthusiasm for my
endeavors. Her wisdom is invaluable to me. In addition, I would like to express my appreciation
to Dr. David Miller, for his expertise in research methods and statistical analyses, his guidance
was important to this project and to Dr. Edil Torres Rivera for his priceless contribution to my
I am deeply indebted to the volunteers and staff of the Alachua County Crisis Center for
their friendship, support and encouragement of my personal and professional growth. In
particular, I would like to thank Dr. Marshall Knudson, the director of the Crisis Center. As my
mentor and my friend, he has helped me develop both professionally and personally into
someone I can be proud of, I hope he is too. Dr. Knudson's life-long dedication to suicide
prevention has been an inspiration for this study.
I cannot express enough gratitude to Shelly Fraser-Mickle, the author of The Turning
Hour, who entrusted her baby to me for this study. She has written a gem for teenagers and
adults alike; I hope I have done her justice in this study.
This study would not be possible without the dedication, hard work and energy of
MaryAnne Wagner, Director of the Language Arts for the Alachua County School Board, who is
the person behind the Turning Hour Project. Her countless hours of work towards this study are
I would like to thank all of the teachers and students who participated in this research. I
appreciate the teachers' willingness to go above and beyond the call of their duty (which is
already a tall order) to teach The Turning Hour to their students. They were courageous to step
out of the box; their work was creative and enlightening. I am grateful to the students who
participated, it is not easy to discuss suicide in a group setting and yet their willingness to open
themselves up produced an immeasurable result to this study.
I thank Caronne Rush and Erin Kelly for the time and energy they put into this project as
presenters. They are a dynamic duo and a tremendous asset to the suicide prevention movement.
I am indebted to my research assistants, Lindsay Leonard, Matt Mustard, Allyn Carey and
Sandy Olsen. I did not envy their tedious task of coding my data but they did it with grace and
utmost care. Their attentiveness to this project made my work so much easier.
I am most appreciative of Ayleen Alexander for her unconditional support throughout this
process. She has been the guardian of my mental and physical health at work and has offered
priceless help with regards to the editing of my work.
I would like to thank Jocelyn Lee, my statistician, who lead me through the incredibly
confusing world of statistics and made difficult work look fun and easy. Her patience, expertise
and willingness to look for a diamond in the rough has made an invaluable difference throughout
I would like to thank Joseph Richardson for his friendship and support as I learned to
juggle the intricacies of a new job with continuing forward with my graduate studies. Our long
conversations and plenty of laughter have helped me become confident and comfortable in my
new position. I am forever grateful to you for trusting me and helping me succeed.
I am deeply grateful to Dr. Marc Gale, my friend and mentor, who has been an incredible
source of encouragement and wisdom as I learned to balance my work, my personal life and this
research project. Thank you, Marc, for believing in me and pushing me to do my very best work.
A very special thank you to my twin sister-Magaly Freytes-who has made this ride
much more enjoyable with her constant humor, love and support. Our friendship is one of the
most important and valuable things in my life-I will cherish you always. We did it!!
I would like to thank my parents for their unwavering support, unconditional love and faith
in me. They have taught me to believe in my dreams and dream big! My parents are truly a
blessing, I have always said, I have the best parents in the world.
I would like to thank my stepson, Dylan James Probert, for his patience and support as I
worked on this dissertation. Throughout this study, his zest for life reminded me that play is as
important to living as work. Thank you, Dylan, for helping me make time to play.
I would like to thank my son, Maximiliano Xirau Probert. Your arrival into this world
gave me the push (shove, really) I needed to finish this study. My cup runneth over with love for
you. I hope that can make you proud of me all your life.
Finally, I would like to thank my husband, James Stevenson Probert, for your patience,
support, love and unwavering belief in me as a person who can be a Doctor of Philosophy. He
challenges me to be the best person I can be without ever taking from me what I have already
accomplished. This study, this dissertation, would not exist if it were not for him. Jim is,
without question, the person most dedicated to the pursuit of a life with substance and purpose-
both professionally and personally--that I know. Our family is enriched because of his presence
in our lives.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ............................................................................................... .......... ..... 4
LIST OF TABLES .............................................................9
ABSTRACT .............................................................. 10
1 IN TRODU CTION ............... .............................................. ...............12
A adolescent Suicide ............................................................... ................... ...............16
Scope of the Problem ....................... ........ ....................................17
Theoretical Framework............... ... ..... .... .... ... .... ........ ...............19
C crisis ............................................... . .......................................... ......................... 19
C risis Intervention .............. ........... ........................................................ 21
Bronfenbrenner's Ecological M odel .............................................................................23
Ayyash Abdo's Application of the Ecological Model to Suicidal Adolescents..............24
State ent of the Problem .................................................................................................. 24
N eed for the Study ............................................................... ................... ...............25
Purpose of the Study ................... ............................................................ .... .. ...............26
N ull H ypotheses........................................ .............. ............................................................26
D definition of Term s ........... ... ... .......................... ................. ..... .......... .........................27
Overview of the R em ainder of the Study .............................................................................28
2 REVIEW OF THE LITERATURE ......................................................................................29
C crisis Intervention Theory ....................................................................................................29
The Ecological M odel, Applied to Adolescent Suicide........................................................35
Bibliotherapy as a D evelopm ent Guide................................................................................44
M ore Inform national A approaches ...................................................................................45
M ore Em otionally Focused Approaches .......................................................................47
T he T turning H our P project ........................................................................... ...............50
Bibliotherapy and Em pirical Evidence..........................................................................50
Suicide Prevention/Education Program s ..............................................................................51
The Turning H our Project................................................................................................. 54
3 M ETHODOLOGY .............. ......... ......................................... ...............58
Sam ple Characteristics.................. ....................................................... ............. .58
V ariab le s ............... .......... ................................................ .......................................... . 5 9
Instrum entation .................................................................................... ......................... 61
Lifelines Questionnaire ................... ...................................... ...............61
Personal Data Sheet............... ........... ...... .. .............. ...............63
N ull H ypotheses........................................ .............. ............................................................63
Research Procedures ................... ............................................................ .... .. ...............63
D ata C collection and A nalyses...............................................................................................65
4 R E S U L T S .............. ......... ................................................ .......................................... . 6 8
Preliminary Analyses ...................... .. ...........................................68
N orm ality.................................................. ............................................................. 68
M easurem ent R liability ............................................................................ ...............69
AN CO V A A nalyses .................... ..... .. ................. ................... ...............69
H hypothesis 1 ................................................................. ................... ...............69
H hypothesis 2 ................................................................. ................... ...............70
H hypothesis 3 ................................................................. ................... ...............71
5 DISCU SSION ................................................................ .......... ........................................................72
Lim stations and Future R esearch...................................................................................74
A INFORM ED CON SEN T FORM S .......................................................................................79
B PE R SO N A L D A T A SH E E T ..................................................................................................80
C LIFELINES QUESTIONNAIRE AND PROGRAM FEEDBACK FORM ..........................81
D ALACHUA COUNTY CRISIS CENTER SUICIDE PREVENTION PRESENTATION ...89
E E D U C A T O R S G U ID E ...........................................................................................................92
F INSTRUCTIONAL VALIDITY CHECKLIST FOR READING BENCHMARKS
ASSESSED BY FCAT GRADES 9-12............ ..............................118
L IS T O F R E F E R E N C E S .............................................................................................................12 0
B IO G R A P H IC A L SK E T C H .......................................................................................................127
LIST OF TABLES
3-1 Outline of Research D esign. ..............................................................................................67
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
THE TURNING HOUR: USING LITERATURE FOR SUICIDE EDUCATION IN THE
Patricia Maria Xirau-Probert
Chair: Silvia Echevarria Rafuls Doan
Major: Marriage and Family Counseling
Adolescent suicide is a salient concern in the United States. It is the third leading cause of
death for our young population (ages 15-24). There have been a number of strategies created to
address this issue, a number of these strategies are directed towards our high school population.
While the typical high school suicide prevention strategy includes a video or a lecture by a
mental health professional followed by a brief classroom discussion, my research examines a
newly developed strategy which combines the traditional suicide prevention information with
literature. The Turning Hour Project uses a fictional peer and her decision-making processes as a
foil to invite teen introspection and discussion about suicide and other real adolescent issues into
the language arts curriculum.
My study compared the impact of this twelve-lesson, literature-based suicide education
curriculum and a traditional suicide prevention presentation upon high school students'
knowledge about and attitudes towards suicide.
The sample consisted of 154 students from six high schools in Alachua County. A pretest-
posttest, control group design was used. There were two treatment groups. Group one received a
suicide prevention lecture from the local suicide prevention agency; Group two received the
same lecture and the Turning Hour curriculum. The teachers who facilitated in this study
participated in a training session prior to teaching their students. Data collected included a
demographic sheet and an instrument to assess the effects of the intervention: the Lifelines
Results indicated a significant increase in a student's willingness to seek help for a suicidal
friend after participating in the Turning Hour Project. No significant improvement in student's
attitudes or knowledge about suicide was found.
Further studies should be conducted to more adequately determine the usefulness of this
strategy by developing a qualitative study for this project where classroom interactions are
accounted for in the results. Further research should focus on refining the psychometrics for this
"'Tis the good reader that makes the good book; a good head cannot read
amiss: in every book he finds passages which seem confidences or asides
hidden from all else and unmistakably meant for his ear."
--Ralph Waldo Emerson
Ralph Waldo Emerson describes the process readers can experience, immersed in a good
book. Often our own experiences are echoed through the voice of a character in a well-written
story. The Turning Hour Project uses literature for suicide education in the schools. Facilitators
report the program inspired even otherwise quiet, reluctant teenagers to talk about real problems
in their lives. This happened in ways they have not seen with traditional suicide prevention
presentations. This suicide awareness program uses literature to reach adolescents and help them
find their voices--to talk about taboo subjects that, when invisible, can devour the lives of young
A variety of school-based suicide prevention programs have been designed in the past
decade. The typical program includes a video or a lecture by a mental health professional
followed by a brief classroom discussion. The Turning Hour Project still incorporates this
traditional school suicide prevention presentation, but it also offers quite a bit more. The
Turning Hour Project offers connection among peers and with adults through literature. This
school-based program uses a fictional suicidal peer and her decision-making process as a foil to
invite teen introspection, in depth. The program weaves thought-provoking discussion about
suicide and other real adolescent issues into the language arts curriculum. This vehicle seems to
inspire more genuine, open engagement with the real struggles in the lives of these teens than a
shorter and more didactic format. The purpose of my study was to determine the effectiveness of
The Turning Hour Project, a high-school based suicide prevention program. This study
compared the impact of this twelve-lesson, literature-based suicide education curriculum and a
traditional suicide prevention presentation on high school students' knowledge, about and
attitudes towards, suicide.
The Turning Hour, which is based on a true story, explores teen suicide. When the novel,
by Shelley Fraser Mickle, commences, Bergin Talbot, a smart and popular high school senior,
has attempted suicide and has been found by her eleven year-old step brother, Dylan. Bergin is
hospitalized and then spends several months in inpatient treatment. Readers are privy to
Bergin's individual and family therapy sessions with the hospital psychiatrist. At the end of
chapter one, Bergin asks herself, "How do I get back?" This question is descriptive of her
struggle to discover how she will be able to get past her attempt to end her life and return to
living a full life. Alternate chapters are narrated by Leslie, Bergin's mother. Leslie, examines
her own life looking for clues to explain Bergin's suicide attempt. Leslie is filled with self-
recrimination as she reveals details about her divorce from Bergin's father and her experience
with post-partum depression after Bergin's birth. Divorce, relationships, sexual intimacy, peer
rejection and depression are among the issues discussed in this book-issues which are the
source of real crises which increase suicide danger among adolescents.
Students who participated in The Turning Hour Project read the book over a period of two
to three weeks. Both in-class and homework reading were assigned. In each classroom, teachers
worked with a school guidance counselor to guide the class through a 12-session program that
combines language arts skills with communication skills. The program itself has been developed
and is compiled in an "Educator's Guide" for The Turning Hour, created by Mary Anne Wagner
with other language arts and guidance specialists (Appendix E). The authors have described
their purpose in the Educator's Guide as follows:
The goal... is to provide assistance to teachers, guidance counselors, ministers and other
helping professionals as they use The Turning Hour in classroom literary study or
counseling group bibliotherapy"... it should be a starting point to facilitate dialogue
between adults and teens. The novel's theme of resilience provides a positive approach to
dealing with tough personal issues (Wagner, Mickle, Page, Myrick, Shaw, Berg, Lucas &
Besides being a suicide education program, the Turning Hour Project is a genuine
literature class. This may be one reason the program appears to be so valuable. The problems in
a student's life are viewed from a traditional mental health and mental illness lens, which may
encourage adolescents to clam up, in order to appear normal. Literature presents the students
with their own problems, viewed as part of the human condition. This project is consistent with
their ongoing study of literature. It is also consistent with respected scholars and experts in
suicide prevention, who view suicide as a multi-faceted human problem deserving multiple
perspectives of response (Shneidman, 1985).
The Educators Guide includes comprehension and vocabulary checklists, a discussion
guide, a character map and a journal. (Appendix E) The comprehension and vocabulary
checklists provide questions which are to be answered in a short answer format by the students.
These questions help teachers examine each student's comprehension of the novel's content and
vocabulary. The discussion questions include; themes from The Turning Hour, (resilience, guilt,
connection, loss), differences in relationships (Bergin's relationship with her father versus her
step-father), and sexual and cultural pressures.
Teachers use these questions to guide the students in a discussion on the novel itself and
issues brought up in the novel. The character guide is used to discuss the individuals in the book
and their relationship to Bergin. This guide is another checkpoint for teachers to insure that
students are tracking the novel. It is also an opportunity for the class to discuss the characters in
detail. Students contribute their opinions of each character and their choices, thoughts and
While the everyday crises students face are reframed and dignified by literature, many
safeguards are in place within The Turning Hour Project. Before beginning the program, all
participating teachers and counselors completed their own training session--preparing them to
spot suicide warning signs which may become visible through the classroom experience. While
the problems adolescents face are normalized, the need for students to get appropriate adult help
for any suicidal peer is clearly emphasized. Students may be more likely to involve adults in
responding to their peers after completing The Turning Hour Project. They may also be more
able to engage their peers appropriately and effectively because engagement is taught
experientially throughout the project rather than only encouraged didactically in a brief lecture
on the value of peer crisis intervention.
Each student was also provided with a journal in which to write their thoughts about the
book and how it relates to their lives. They were given prompts to help guide their answers. The
students were made aware that the journal is a private form of communication between
themselves and the guidance counselor. This journal is believed to have its own intrinsic value,
potentially helping students work through difficult issues and solidify new coping skills. The
guidance counselor read each journal and returned it to the students with comments. If a student
writes anything of concern in their journal that may require more action than a written comment,
the guidance counselor can decide how to respond appropriately.
A traditional suicide prevention presentation was incorporated into the project. A suicide
preventionist from the community attended one session with each group. This presentation on
suicide included a profile of warning signs for adolescent suicide, an outline of what helps and
what is not helpful in responding to a suicidal peer, and an introduction to local resources in the
community (Appendix D). Students received brochures with information about the Alachua
County Crisis Center and a national suicide prevention hotline. For the purpose of research, this
traditional suicide prevention presentation was identified as a second treatment within the
experimental design to study its separate and interactive effects. The Turning Hour Project has
always included this essential component.
On Tuesday, September 30th, 1997, Katja took an overdose of antidepressants. She died
around 3:00am. She was 19 years old. On November 7th, 1999, Trevor hung himself from a
steel beam in the basement. He was 15 years old. On June 20th 2005, Aaron shot himself in the
mouth with his father's gun. He was 13 years old. These and other similar tragedies are re-
enacted every day, every hour across the United States of America (American Association of
Suicidology, 2004). Adolescent suicide is a tragic problem for our society. In 2004, 4,316 young
people (ages 15-24) decided that the only way to cope with the pain they were enduring was to
end their life (American Association of Suicidology, 2007). This number is reflective of the
maladaptive coping skills being learned by adolescents in the U.S. In a discussion on suicide
and adolescents, Goldman and Beardslee (1999) point out that "suicide may be a way of
attempting to regain control for someone who feels truly out of control and unable to handle the
situation more reasonably and rationally" (p. 422). When an individual feels unsupported and
disconnected from his family and peers, he becomes hopeless that his life will change for the
better. At this point, suicide can become the only option that seems viable.
One of the greatest myths about suicide is that by talking about it, we will put the notion
into a person's head and increase the chances that they will kill themselves. This is like the
argument against sex or drug education. Classroom lessons will not be the first exposure to kids
on any of these topics. We only stand to lose an opportunity to make a difference by pretending
the problem of suicide does not exist. The invalidity of this idea has been stated repeatedly in
the literature. Kalafat and Elias (1992) explain that talking about suicide will not plant the idea
in the heads of adolescents, because they are aware of suicide from their experience with suicidal
peers and the media (Kalafat & Elias, 1992). Clinicians in the crisis center movement state that
the need to avoid planting the idea of suicide is a myth (e.g. A.C.C.C. Training Manual, 2004).
The Center for Disease Control and Prevention has stated in regard to school-based suicide
prevention and education programming, "there is no evidence of increased suicidal ideation or
behavior among program participants" (Youth Suicide Prevention Guide, 1992). There is
evidence that participants of school-based suicide prevention and education programs are more
likely to intervene and tell an adult about a suicidal peer than those students who do not
participate in these programs (Kalafat & Elias, 1994; Eggert, Thompson, Herting, & Nicholas,
1995; Kalafat & Gagliano, 1996).
Scope of the Problem
Suicide is the third leading cause of death among teenagers, ages 15-19 in the United
States of America. The rate of suicide for children ages 10-14 increased 100% from 1984 to
1996. There is an average of 84 suicides daily in the United States. Twelve of these are aged
15-24 (McIntosh, 2000). Perhaps a more dramatic statistic is that "within every 2 hours and 15
minutes, a person under the age of 25 dies by suicide [and] for every completed suicide by youth,
it is estimated that 100 to 200 attempts are made" (American Association of Suicidology, 2004).
Sixty percent of American adolescents have reported some history of suicidal ideation. In a
typical American high school classroom of 30, there will be one boy and two girls that will
report having either thought seriously about or having actually attempted suicide in the last
Reports show that females are three to four times more likely to attempt suicide, whereas,
males are 4.8 times more likely to die by suicide. Males are more likely to use firearms than
females; research consistently shows that firearms are the most common suicidal method chosen
by American adolescents to complete suicide, regardless of race or gender (American
Association of Suicidology, 2004). In his research, King (1999) finds that, "girls are one and a
half to two times more likely to report suicidal ideation than are adolescent boys" (p.63). He
suggests that this may be due to differences in socialization and cultural expectations between
young males and females.
Today's society does not offer sufficient opportunities for teenagers in general to talk
about their concerns, their pain or for them to truly connect with their peers and with the adults
in their lives. Adolescent goals often center on obtaining high academic scores and having an
acceptable social life. The pressures can often feel insurmountable. And most teens feel that
there are not many, if any, safe places to talk about their fears. After all, that would not be
In their chapter on adolescent suicide, Goldman and Beardslee (1999) explain that
communication between adults and children is a protective factor against depression for
adolescents. Having adults who help teens normalize their emotions and developmental
processes is crucial to the prevention of suicidal behaviors (424). When individuals feel isolated,
misunderstood and unloved they are experiencing a disconnection from their world. This
disconnect limits the resources available to them in the moment when they need it most.
Although there continues to be an immense need for suicide education and intervention
with adolescents, there is an unfortunate dearth of empirically-based programs in place. Students
and school personnel are in a key position to prevent adolescent suicide and yet their knowledge
and training in suicide related behavior continues to be inadequate (Mazza, 1997; Miller &
Pam Harrington lost her teenaged daughter to suicide in 1997. Since then she has become
an activist in suicide prevention and awareness. She travels around the country talking to
government leaders about suicide. Pam was preparing for a lobbying trip to Tallahassee, Florida
when she impulsively packed one of her daughter's beloved jigsaw puzzles. She was not sure
what she would do with this box of puzzle pieces but had faith that her impulse would lead to
something good. As she was finishing her talk with a diverse group of leaders, she gave them
each a piece of her daughter's puzzle and said, "you now have a piece of my daughter's puzzle-
perhaps if we all work to put these pieces together we can come closer to solving the puzzle of
suicide." (Pam Harrington, 2000).
My research will be grounded primarily in crisis intervention theory and Bronfenbrenner's
ecological model of social influence, specifically as applied to adolescent suicide by Huda
Ayyash-Abdo (2002). Bibliotherapy and existing research on school-based prevention/education
programs will also be utilized.
The core assumptions of Crisis Intervention Theory are spelled out articulately by Gerald
Caplan (1964) in his groundbreaking book, Principles of Preventive Psychiatry. A crisis is
clinically defined as an imbalance between a stressor and the coping resources available to an
individual. Caplan explains that when individuals are in a non-crisis state, they maintain a level
of homeostasis. He proposed that most of the time, people solve their problems using strategies
that they have learned over the course of their lives, habitual coping mechanisms. As long as a
person's stressors are in balance with the internal and external resources available to them, they
are able to maintain that level of emotional homeostasis.
People go into crisis, Caplan explains, when events occur that create an imbalance between
their stressors and resources. At this point, people's coping skills are not adequate to resolve the
difficulty. People in a crisis state will repeatedly use their existing resources, trying to cope with
the situation. As they fail time and time again, their frustration level will increase as they
become unstable and their functioning processes become disorganized. Caplan outlines the
intense emotions people in crisis frequently experience at this point. These include hopelessness,
helplessness, anxiety, fear, anger, grief and shame.
An important concept in crisis theory is the belief that this crisis reaction should not be
viewed as a form of pathology but rather as a normal response to a loss or traumatic event.
Caplan argues that everyone is vulnerable to this experience of crisis. No matter the extent of
resources and coping skills, at some point in their lives, everyone will likely experience a
stressor beyond their ability to cope. Yet, Caplan argued that all people have the opportunity to
gain strength and additional resources through a crisis situation--if they receive the appropriate
kind of help at the right time (Caplan, 1964).
Dr. Marshall Knudson is the Director of the Alachua County Crisis Center and a national
leader in suicide prevention. He elaborates on Caplan's explanation in his lectures on crisis.
Knudson describes the four ways in which people typically resolve the chaos and unbearable
pain experienced at the height of crisis. Optimally, people will experience growth, resolving
their crises by gaining new coping skills. These are the stories of something good coming out of
real loss. The next best outcome is for people to return to roughly the same level of functioning
they experienced prior to the loss. The loss may leave scars, but one day people feel and act
more like their old selves again.
Unfortunately, these two outcomes are not always what occur. Knudson explains that a
third possible outcome during a crisis is for people to develop psychopathology or lose aspects of
their previous functioning. At other times, and Knudson's fourth possible outcome, when they
cannot find any way to resolve the crisis, for better or worse, people may become suicidal.
Unable to see any other escape from the unbearable pain, they may begin to consider killing
Caplan (1964) proposes there is a fairly narrow window in which appropriate and optimal
crisis intervention can be achieved. He describes crisis intervention as short-term and goal
directed. Caplan notes that peak crises last four to six weeks, after which there will be
movement toward psychiatric impairment or growth. Caplan emphasizes that crisis intervention
must take place as soon after the loss or traumatic event as possible. Immediate stabilizing of
emotional conflicts can help the individual in crisis move through the process of crisis resolution
in a healthier manner. Caplan states that people in crisis tend to be more open and willing to
accept a helper's interventions than they are when in a more balanced emotional state. Effective
intervention, according to Caplan (1964), includes understanding through listening and
acknowledgement of feelings. It is important to allow people in crisis to grieve, scream, cry,
shout in anger, and in general to feel their feelings. This acknowledgement of emotions is
crucial because it allows the person in crisis to confront the realities of the situation-both the
external event and the inner response. It is premature to attempt to problem solve before people
in crisis are able to face and begin moving through the emotional chaos of their own response.
Caplan (1964) emphasizes the importance of being direct with people in crisis and
avoiding any false reassurances or incorrect information. Facing the reality of a situation allows
the individual to begin to make sense of how the event is impacting them. Factual information
and an accurate picture of what they are facing will help the person in crisis approach the trauma
from a place of strength. (p.294)
Erich Lindemann is considered the founder of modern crisis intervention and had a
significant influence on Caplan. In 1943, Lindemann documented his observations from work
with people involved in an infamous fire at the Coconut Grove nightclub in Boston. The
Coconut Grove fire occurred on the eve of a Harvard-Yale football game. Four hundred, ninety-
one people were killed, and 39 survivors were brought to the Massachusetts General Hospital for
treatment of bums. It was with these patients that Lindemann began to observe and document
grief reactions. Survivors, families and friends were left in various stages of crisis. Lindemann
noticed that as he and his team talked to the patients, in order to develop psychiatric histories,
their grief symptoms began to decrease. The summary of his findings on human reaction to loss
became the fundamentals of crisis theory which serve as a "conceptual framework for preventive
psychiatry" (Caplan, 1964, p.10). Lindemann outlines five major characteristics of grief: (a)
somatic stress (disruption of normal sleep, loss of appetite), (b) preoccupation with the image of
the deceased, (c) guilt (d) hostile reactions, and (e) loss of patterns of conduct (Lindemann,
Lindemann notes that it is common for people to avoid the intense pain caused by the loss
of a loved one and that most people who effectively grieve a loss do so with much effort.
The duration of a grief reaction seems to depend upon the success with which a person
does the grief work, namely, emancipation from the bondage to the deceased, readjustment
to the environment in which the deceased is missing, and the formation of new
relationships. One of the big obstacles to this work seems to be the fact that many patients
try to avoid the intense distress connected with the grief experience and to avoid the
expression of emotions necessary for it (p. 143).
These statements create a profile of what a person looks like in a crisis state and
acknowledge the difficulty of working through the grief. Often, it is not only the people in crisis
who want to distance themselves from the pain, it is often also the people trying to help them.
Helpers often move directly into problem-solving to avoid being exposed to the intense emotions
of those in crisis.
It is important to understand that Lindemann's and Caplan's vision of crisis intervention is not
limited to help at the professional level. Their vision of optimal, system-wide prevention
includes people in the immediate lives of those in crisis also being able to help those people
grieve. It includes preparing those who will be in crisis to understand the value of this kind of
everyday support, as well. The goals and methods of The Turning Hour Project are highly
consistent with that vision of prevention.
Bronfenbrenner's Ecological Model
Bronfenbrenner's ecological model (1977, 1979) describes how varying circles of
influence impact an individual. His intention in proposing the model is to demonstrate that no
one factor should be viewed alone, apart from the others. Bronfenbrenner uses a visual similar to
a bulls-eye, placing the individual in the center. Each concentric circle around the individual
represents a broader circle of influence: in order, the microsystem, exosystem, and
macrosystem. The microsystem includes immediate influences on an individual, such as family
and friends. The exosystem encompasses a larger environment surrounding the individual, for
example, the neighborhood in which he or she lives. The macrosystem, the outermost layer,
represents the larger culture, including the over-arching beliefs and values, which impact how
decisions are made within the system.
In 1980, Belsky added a final, inner-most circle to the ecological model, representing
individual ontogenic development (Ayyash-Abdo, 2002). This layer includes factors inherent to
the individual, for example, psychological characteristics such as the experience of hopelessness.
Each of these four layers interacts with the others, thereby, having complex influence on the
Ayyash Abdo's Application of the Ecological Model to Suicidal Adolescents
Huda Ayyash-Abdo (2002) wrote an article, Adolescent Suicide: An Ecological Approach,
in which she uses Bronfenbrenner's model as a framework to organize adolescent risk factors for
suicide. This model moves the focus beyond the individual, to include a broader, systemic view
of the problem. Ayyash-Abdo's approach provides a foundation from which to begin putting
together a more holistic view of the suicidal adolescent, in which various factors influence the
individual from multiple levels. Ayyash-Abdo (2002) applies Bronfenbrenner's model to
adolescent suicide risk factors to show that suicide is also a community issue and not only an
individual issue. As this paper will elaborate in the next chapter, many of the problem areas
highlighted by Ayyash Abdo are specifically addressed by The Turning Hour Project.
Statement of the Problem
Kalafat and Elias, (1992) surveyed 325 suburban high school students regarding their
knowledge of suicide. Specifically, the researchers wanted to know if this sample population
had ever talked to a suicidal peer and, if so, how they had responded. Kalafat and Elias found
that 68% of females and 42.5% of males had known of another teen who had talked about or
attempted suicide. The majority (63%) of these students took it upon themselves to help the
suicidal peer without telling an adult. The results of this study emphasize the need to talk to
adolescents, assure them that adults are aware that suicide is an issue for this age group, and
teach them basic prevention skills that include involving an adult.
A variety of school-based suicide prevention and education programs have been designed
in the past decade. These programs often include a didactic presentation and a discussion.. For
example, the SOS Suicide Prevention Program provides teachers and counselors with a video
that teaches students helpful and hurtful ways to respond to a suicidal individual. The video also
interviews persons who have either attempted suicide or lost someone to suicide. A guide is
provided to help an adult facilitate the discussion (Aseltine, 2002).
While The Turning Hour Project includes the traditional "do's and don't" of suicide, it
offers more as well. The Turning Hour Project offers human connection through the study of
literature. The project incorporates discussion about suicide and other real adolescent difficulties
into a language arts program. This intervention may evoke more genuine, open engagement with
the real struggles in the lives of adolescents. It may also lead to measurable differences in how
adolescents understand suicide and their own potential response to a suicidal peer.
Additionally, while teachers, librarians and mental health providers have observed the
usefulness of bibliotherapy and their belief that it has a positive impact on the children and adults
they work with in educational and therapeutic settings, there is a lack of empirical research in the
area of bibliotherapy as a tool that helps people cope with emotional concerns (Corr, 2003-2004).
Need for the Study
As suicide continues to be a leading cause of death for adolescents, there is a heightened
need for effective strategies in the field of suicide prevention. Research with high school students
indicates that teenagers are more likely to confide in each other regarding their own suicidal
thoughts and feelings. Research also reveals that adolescents will more typically take it upon
themselves to help a suicidal friend rather than seek an adult's help (Ross, 1985; Kalafat & Elias,
1992; Hennig, Crabtree, & Baum, 1998). These two findings support the need for adolescents to
be educated about suicide and suicide prevention. They also show the need for programs that
foster and encourage communication between teenagers and adults about an issue as serious as
Purpose of the Study
The primary purpose of this study was to explore the effectiveness of The Turning Hour
Project, as a school-based program. The study compared the impact of this literature based
suicide education curriculum and a traditional suicide prevention presentation (made by staff
from the Alachua County Crisis Center) on high school students' knowledge about and attitudes
towards suicide. The impact was measured by a questionnaire that addresses knowledge about
adolescent suicide warning signs, attitudes towards help-seeking with a suicidal peer, and self
efficacy in help-seeking behaviors when approached by a suicidal peer. Students from six high
schools in Alachua County (three rural and three urban) participated in this study. The goal of
this research was to provide knowledge about ways both to increase the level of suicide
awareness in high school students and to increase the likelihood that they will intervene
effectively with a suicidal peer. The information gained from this study may be used by
suicidologists to develop more effective suicide prevention and education programs for school
This is a quasi-experimental study in which data from high school students assigned to two
treatment groups (A.C.C.C. lecture plus Turning Hour Project or A.C.C.C. lecture only) were
compared to each other and to data from other high school students assigned to a control group.
Data was collected for the following: (1) demographic variables; (2) attitudes towards peers with
suicidal thoughts; (3) knowledge of suicide intervention concepts; (4) self-reported feelings of
The following null hypotheses were investigated:
Hol: There will be no significant difference in knowledge of suicidal behavior between
the groups of students based on their participation in the suicide prevention program.
Ho2: There will be no significant difference in attitudes towards help-seeking and
intervening with suicidal peers between the groups of students based on their
participation in the suicide prevention program.
Ho3: There will be no significant difference in students' degree of self-efficacy in suicide
related help-seeking behaviors when approached by a suicidal peer between the groups of
students based on their participation in the suicide prevention program.
Definition of Terms
Active Listening is a therapeutic term that describes skilled listening where an individual
paraphrases statements made by the person they are listening to, reflects feelings and summarizes
what they hear the other person saying. The goal of active listening is to communicate to the
other person that their thoughts and feelings are being heard and understood.
Suicide is defined as the act of voluntarily terminating one's own life.
Suicide Education is defined as a formal program that teaches individuals about suicide. This
includes data on suicide statistics in the United States, explanation of suicide related warning
signs, suicide related help-seeking behaviors and local resources for suicidal persons.
A Suicidal Adolescent is defined as an individual between the ages of 13-19 who is considering
killing him or her self.
Crisis is defined as a period of psychological imbalance experienced as a result of a single or
multiple stressor(s) that an individual perceives as a threat. During a crisis, individuals realize
their coping skills are not adequate to help them regain equilibrium.
Crisis intervention is the process of providing immediate psychological assistance to an
individual experiencing a crisis. Crisis intervention involves attending to immediate emotions,
acknowledging the full reality of a loss or trauma, and developing short-term goals.
Suicide Prevention is defined as the process by which individuals are educated and trained to
recognize and intervene, as appropriate for their given roles, with a suicidal person.
Overview of the Remainder of the Study
The remainder of this study consists of four chapters. Chapter Two is a review of related
literature. Chapter Three contains a description of the methodology, subjects, and research
design. In Chapter Four, the results of the study are presented. Chapter 5 includes a discussion
of the results, conclusions, implications, limitations and recommendations.
REVIEW OF THE LITERATURE
This chapter reviews the professional literature relevant to this study. The review is
organized into four major sections: (1) Crisis Intervention Theory, (2) the Ecological Model,
Applied to Adolescent Suicide, (3) School-Based Suicide Education/Prevention Programs, and
Crisis Intervention Theory
This elaboration of crisis intervention theory will provide central theoretical support for the
validity of the Turning Hour Project. The theory, based largely on the work of Caplan (1964)
and Lindemann (1944), proposes that people in crisis should not be viewed as mentally ill, but as
having normal reactions to intense loss. Generally, Caplan writes, "a person operates as an
individual and as a member of society in certain persistent patterns with minimal self awareness
and sense of strain" (1964, p.38). That is, a person who is not in crisis lives with the relative ease
of having stressors and resources in balance. It is when the stressors outweigh existing resources
that a person goes into a crisis state. Then, the person may be overwhelmed by intense emotion
and feel helpless to regain any balance. Crisis intervention helps the person re-stabilize and then
find ways to cope with the new stressors (Caplan, 1964).
This model focuses on regularly occurring human dilemmas without resorting to
psychopathology as an explanation. It supports respecting people as competent experts in their
own lives, but who may need more attention and guidance during times of crisis. Even then, the
focus remains on empowering people to resolve their own problems. Crisis intervention steers
away from personal interpretations or clinical understandings of other people's personalities and
difficulties. Crisis intervention focuses only on the crisis at hand and whatever must be dealt
In crisis intervention, there are two preliminary steps to be taken before problem-solving of
external difficulties begins (Young, 1998). The first priority is to attend to the immediate safety
of the person in crisis. For example, with a woman who has just been raped, it is important to
see if she is safe from her attacker and if she needs immediate medical attention. With a suicidal
individual, this first priority is to ensure immediate safety. For a telephone crisis worker this can
mean working to see if a gun can be unloaded or pills can be moved out of immediate reach.
Crisis intervention focuses on empowerment, emotional experience and individual responsibility,
but not at the expense of life or limb. For a student or a teacher, this still means involving a
trained responder as soon as possible, to address the potential danger faced by a suicidal
After immediate safety is addressed, the next priority is attending to the intense emotions
of trauma and loss. In his research of the 1942 Coconut Grove nightclub fire, Lindemann found
that survivors of this disaster who developed serious psychopathologies had failed to go through
the normal process of grieving. Beyond grieving a death, this basic idea can be applied to
anyone who experiences a "serious, sudden loss" (Hoff, 1995, p.11). Individuals who have just
experienced a trauma are helped to express their emotions and grieve their loss. Only after this
has been done are people naturally ready to participate with a helper in problem-solving. At this
point, as they regain contact with their own inner resources, they will often require less
Crisis intervention theory proposes that a relatively small contribution from a helper can
make a significant, long-term difference in another person's well-being. Although a particular
crisis may sometimes be avoided, crisis in general is seen as unavoidable. The psychological
crisis is an immense force of change, with the potential to alter a person's life irrevocably. The
helper takes advantage of this powerful change process and believes that a relatively brief
response, made at the right time in the right way, can tip the scales of an individual's life toward
a healthier resolution. The emphasis is on helping individuals resolve crises in such a way that
their lives are enriched rather than diminished.
As the Chinese symbol for crisis represents danger and opportunity, the goal of crisis
intervention is to avoid the danger and take advantage of the opportunity (Hoff, 1997). Crisis
intervention is not therapy. Caplan (1964) states that an individual in crisis may actually rework
or expand limited and unhealthy coping responses developed in previous crises. Yet a helper
guided by the theory of crisis intervention does not set out purposefully to uncover old wounds
or address longstanding symptoms. The focus remains on facing the emotions and difficulties
threatening the individual in the moment the crisis is occurring.
While achieving them may be difficult, Crisis Intervention theory presents a simple,
elegant set of goals. Crisis intervention is immediate. Crisis theory supports helpers to respond
as soon as possible. The earlier people in crisis are able to get help, the better their chances of
regaining their pre-existing state of well-being, or even of improving beyond that (Parad &
Crisis intervention has been referred to as "emotional first aid" or "psychological triage"
(Brock, Sandoval & Lewis, 2001). There is a small window in which individuals will respond
most effectively. If this window is missed, crisis intervention is less likely to be helpful. The
emotions that a helper works to reflect are once again buried deeply and the strict crisis
interventionist is left without tools to reach them.
In 1944, Erich Lindemann published his study of 101 survivors of the Coconut Grove
fire. Among these were injured survivors of the fire, their families and family members of
victims killed by the fire. Based on his observations, Lindemann coined the term "grief work."
Essentially, it involves only two goals. 1) To help people in crisis to feel whatever emotions
they have to feel in order to move beyond the emotional disorganization and disconnection of the
crisis state. 2) To help them take whatever energy was once invested in their lives with those
who died (or whatever was lost) and bring it back somehow into the process of living.
Caplan (1964) essentially restates the same process, encouraging the person to face the
emotional and tangible realities of the crisis squarely. He encouraged helpers to speak directly
about the crisis and avoid false assurances. Arresting the process of grief and loss can lead to
psychopathology to more permanent states of disorganization and disconnection. It can also lead
to maladaptive coping responses such as substance abuse or withdrawal into social isolation.
Therefore, the goal of crisis intervention is to help individuals in distress face intense, potentially
crippling emotions and then reengage their resources and the world until they regain their
previous balance or even gain a more productive or satisfying balance.. Crisis intervention
requires helpers to direct the individual in crisis to face reality and make a commitment. The
individual must face the emotional devastation of a loss, in order to commit to finding a way
back into life without it.
As envisioned by its originators, crisis intervention does not have to be carried out by
medical or mental health workers. As a psychiatrist, Caplan (1964) specifically envisioned crisis
intervention as a preventive step, whenever possible, to avoid the regression toward over-reliance
on expert medical understanding and decision making that can come with medical treatment. Of
course Caplan's concern need not be taken concretely. For instance, treatment for depression
may help some individuals regain the ability to face the difficulties in their lives.
Crisis intervention is flexible and expansive. Non-practitioners, such as volunteers,
ministers and others can be taught crisis intervention skills (Hoff, 1995). Caplan writes, an
individual "does not usually face crisis alone, but is helped or hindered" by the influence of
"family... .friends ...community... even nation" (1964, p. 42). What is most important, he
continues, "for maintenance of mental health and avoidance of mental disorder is that the
activities of the family or other primary groups be directed to helping the person in crisis deal
with" the problem.
Crisis intervention theory provides an essential theoretical basis for understanding the
value of The Turning Hour Project. When difficult issues like depression, substance abuse and
even suicide are viewed only within the expertise of medical and mental health providers, then
students, teachers, family members and others can be kept from participating as fully as possible
in addressing the real problems facing adolescents every day. Crisis intervention was originally
intended to guide those in the immediate social environments of people in crisis. Caplan (1964)
understood professional resources are too scarce. They cannot be present in all those critical
moments when a crisis will make or break some individual's future.
Crisis intervention theory supports the legitimacy of teaching adolescents collectively to
face their own problems, work through their own painful emotions--and then also to seek
additional help when they need it. It shows how necessary that work is. Crisis intervention
theory reframes human loss and trauma-and the suffering that accompanies them-out of strict
medical interpretation and back into a broader human understanding.
A quote from Caplan's (1964) Principals of Preventive Psychiatry specifically
demonstrates his appreciation of learning from literary depictions of crisis. Crisis theory, Caplan
explains, (in the original, non-inclusive language of the time):
is consonant with the popular views on crisis as a turning point in life development
exemplified by the writings of novelists and dramatists. Many plays focus on the reactions
of an individual and his personal network in dealing with a temporarily insoluble problem.
The even tenor of his life is upset by some unexpected happening, and with the help and
sometimes the hindrance of his associates, he is portrayed struggling to find a way out of
his predicament. The excitement of the play consists in the difficulty of predicting the
outcome and in the identification of the audience with the actors as the tension rises to a
climax in confronting the challenges and threats to their fundamental needs without
knowing how to deal with them. In many plays the tension stimulates the emergence of
unexpected capacities in the characters, and these sharpen the dramatic struggle.
Eventually, a series of trial-and-error explorations leads to a resolution of the problem and
of the tension. Characteristically, this resolution is polarized as good or bad, and, when the
play ends, the central characters have settled down to a new equilibrium in which they are
clearly better or worse off than they were when the play started. From our point of view,
one of the significant aspects of many modern plays is the implication that the outcome is
determined by the choices which the characters make in coping with the situation. (pp.34-
Caplan's view of crisis and this description have a remarkable resonance with the Turning
Hour Project and the original goals of its creators-that participants will learn to cope better with
their own crises and with those of their peers.
In the Turning Hour Project, students follow Bergin Talbot through her own struggle to
discover how she will be able to get past her suicide attempt and return to living a full life. The
students are empowered, experientially, to face the painful realities of real crises and dilemmas
in their lives. They are empowered to speak directly about divorce, relationships, sexual
intimacy, peer rejection and depression and begin making more direct sense of how they can deal
with these issues. They are encouraged by the structure of the curriculum to connect with each
other, to develop more confidence in their ability to support each other through these difficult
struggles. At the same time, they are also encouraged by Bergin's example. There are times
when the magnitude and danger of their crises will require involving expert help from the adult
world. In the full context of the Turning Hour Project-including the teachers, counselors and
administrators involved in making the project real-- the adolescents are given an example that
expert adult help can be both protective and empowering.
The Ecological Model, Applied to Adolescent Suicide
In this section, I will elaborate the ecological model as used by Ayyash-Abdo (2002) to
address adolescent suicide, including the risk factors she names at each systemic level. I will use
her model as a level-by-level guide for understanding the problem of adolescent suicides. I will
also weave in research from other authors to flesh out the model.
The ecological approach, Ayyash-Abdo writes, resists the tendency to focus solely "on the
adolescent's personal history, such as depression, hopelessness, substance abuse, etc. and depicts
suicide as a result of an interaction among a number of factors (personal, interpersonal, and
socio-cultural) that are directly or indirectly related to adolescents" (p. 461, 2002). This
systemic view is crucial to the development of suicide education programs in the school system.
The focus of these programs should not be based solely on those adolescents who score highest
on depression or hopelessness scales or who have previous suicide attempts (although it is
critical that we do not lose sight of these children either). Suicide education programs should
reach out to every adolescent in order to counteract negative messages or influences that may be
at work within the four levels of the universes those adolescents inhabit.
Ontogenic development is the level added by Belsky (1980) to include person-oriented
factors in the ecological model. An individual's historical, medical, and psychological
development will interact with influences from the other three layers. In the case of suicide,
Ayyash-Abdo (2002) identifies depression, hopelessness and substance abuse as the key risk
factors at this level. Another significant risk factor identified by suicidologists and belonging at
this level is previous suicide attempts (Watkins and Guitterez, 2003).
Depression is identified as the strongest and most consistent correlate of adolescent
suicidal behavior (Brent et. al, 1992; Shaffer, et. al., 1996; Mazza & Reynold, 1998; Mazza,
2000). Rhode, Lewinsohn and Seeley's (1994) study, which examined what characteristics that
are present in adolescents' thinking about suicide, found that a significant number of teens who
were contemplating suicide also reported signs of depression. Researchers have linked
depression as a major predictor of suicidal ideation (Mazza, 2000: Doan, Roggenbaum, &
Lazear, 2003). Depression can interfere with an individual's thinking to the point where he or
she no longer sees or thinks clearly. In this state, a person's options may seem more limited than
they actually are.
Two types of depression have been identified: biological and situational (Opalewski,
2001). Biochemical depression involves changes in the brain structure or brain function.
Biochemical depression may be inherited; however, it can also occur in individuals with no
family history of depression (The National Institute of Mental Health, 2006). Situational
depression occurs when an individual experiences a crisis event such as the loss of a loved one,
which causes feelings of deep sadness and hopelessness. Young adults with a parent who dies or
who loses any significant relationship in their lives can become depressed to the point where
they begin to think suicide is the only way to alleviate the pain.
Depression in teenagers has been found to increase other risk factors such as alcohol and
drug abuse, anxiety disorders, decreased interest in academics and extracurricular activities and
withdrawal from peers and family (Hess et. al, 2004). Research suggests that as many as 7% of
teenagers diagnosed with a major depressive disorder commit suicide (Weismann, et al., 1999).
Clinicians focusing on suicide prevention in the general population have considered
hopelessness to be one of the most significant warning signs (Knudson, personal
communication). Yet, the empirical study of hopelessness and suicide in younger people is
relatively new. According to Ayyash-Abdo (2002), results have been inconsistent. She singles
out a study by McLaughlin, Miller and Warwick (1996), who report "hopelessness is a more
powerful predictor of adolescent suicidal behavior than depression" (p. 462). Other researchers
(Joiner & Rudd, 1996; Mazza & Reynolds, 1998; Beautrais, Joyce, & Mulder, 1999) have not
demonstrated as strong an association between hopelessness and suicide.
Substance abuse has also been identified as a significant risk factor of suicidal ideation in
teenagers (Thompson et al., 2002). In a study on the association between adolescent suicide and
drug use, Hallfors, et al. (2004) reported a significant increase in depression, suicidal ideation
and suicide attempts among teens who used alcohol and drugs, compared to those who abstained
from drinking, smoking or other drug use.
The risk of a completed suicide is higher among teens with a history of suicide attempts.
"For every completed suicide by youth, it is estimated that 100 to 200 attempts are made. In grades 9
through 12, 8.8% of students attempted suicide in the previous 12 months (6.2% male and 12.2%
female)"( American Association of Suicidology, 2004). In their summary of suicidal risk factors
in the literature, Watkins and Guttierez, (2003), identify that a history of previous suicide
attempts is the strongest predictor of future suicide attempts. Shaffer (1998) asserts, "the risk for
future suicide attempts increases twenty-fold with individual's history of prior attempt"
School-based suicide education programs can attend to the ontogenic level by addressing
these issues. In general, suicide educators should be aware of the ontogenic risk factors and
optimally include discussion and education on depression, hopelessness, substance abuse and
suicide attempts. The main character in the Turning Hour makes a suicide attempt. The
dialogues with her therapist that follow address depression and loss at length. The Turning Hour
Project incorporates significant discussion of the main character's feelings, including her
hopelessness at the time of the attempt, her subsequent struggles and increasing optimism. The
curriculum brings ontogenic risk factors into real life discussion within the classroom.
Ayyash-Abdo (2002) indicate that the "most immediate influences on adolescent suicidal
behaviors are within the microsystem" (p.462). This level of the microsystem is comprised of
those people and environments that are in constant contact with the individual. The microsystem
includes family, friends, school and peers.
In her article, Ayyash-Abdo (2002) discusses the impact that family history has on an
individual. Research findings suggest that adolescents who have lost a family member to suicide
are at greater risk for attempting or completing suicide than adolescents who have not
experienced this loss. The American Association of Suicidology explains that youth who
repeatedly attempt suicide usually have a history of suicide in their families (American
Association of Suicidology, 2004). A recent study (Agerbo et al., 2002) examined risk factors
for suicide in adolescents based on data received from the national Danish registry. The
researchers found that teen suicide was five times more likely in those individuals who had lost a
mother to suicide and twice as likely in those individuals whose father completed suicide. This
population-based nested case control study adjusted for parental psychiatric history.
Evidence consistently suggests that there is a connection between suicidal behavior and
dysfunctional family origins in general. This may include substance abuse disorders and
antisocial behaviors (Agerbo et al., 2002; Brent et al., 1988, 1996; Gould et al., 1996). Other
familial events that may affect and increase suicide ideation are parental loss by separation,
divorce and a history of physical or sexual abuse during childhood (Agerbo et al., 2002; Brent et
al., 1988, 1996; Gould et al., 1996).
Goldman and Beardslee (1999) explain that because adolescents live so intensely within
the family matrix any factor that impacts the functioning of the family will have a significant
effect on the child. If the family has poor coping skills and does not communicate adequately
about what happens to them, the child incorporates this dysfunction and is at a greater risk for
becoming self destructive.
Adolescence is a time where there is a need for intimate relationships among peers with a
distancing from parents. Ayyash-Abdo (2002) discusses the changes in this developmental stage.
She notes that teens begin to rely on their friends for support and approval more than they do on
their parents. Ayyash-Abdo (2002) adds that adolescents begin to share their innermost thoughts
and feelings with their friends during this phase of development. Teens often help each other
cope with problems or conflicts that arise. Because of this Ayyash-Abdo identifies loneliness as
a significant concern during adolescence as well.
Low peer support has been identified as a predictor of depression, conduct problems and
substance abuse issues (Ayyash-Abdo, 2002; Beautrais, 2001; Aseltine, Gore, & Colten, 1998).
These are all risk factors for adolescent suicide. Teens who attempt suicide have consistently
been identified as alienated from their peers or as having experienced a significant loss such as a
break-up with a boyfriend or girlfriend (American Association of Suicidology, 2004). In a study
examining the effects of perceived peer and family support (Harter et al., 1996), researchers
found that those adolescents who felt connected to their families and peers and who believed
themselves to be supported by them had a greater sense of self worth and lower levels of suicide
ideation. Other studies have shown that those adolescents who lack social support have higher
rates of suicide ideation and other self-destructive behaviors (Grholt et al., 2000, Spruijt & de
Ayyash-Abdo (2002) noted that research findings link poor academic performance to
adolescent suicidal behaviors. There are researchers who have found a correlation between
school work and self destructive behaviors. For instance, Gould, et al., 1996, conducted a study
that investigated the psychosocial risk factors in adolescents who had completed suicide. The
researcher performed psychological autopsies of 120 suicides completed by individuals younger
than 20 years of age. Problems in school were among the most significant factors found.
At the same time, there are studies which report no clear relationship discovered between
poor school performance and suicide ideation. Ayyash-Abdo's review of the literature suggests
an interaction effect between low school performance and other risk factors in the ontogenic or
microsystem levels. Together, these predict higher risks of suicide ideation (p. 465). This is
consistent with the previous discussion of how an individual's perception of support from peers
and family interacts with other factors to affect suicide risk. The advantage of the ecological
model is not only to identify the interaction of adolescent suicide risk factors at various levels,
but also to suggest interventions that might address the risk systemically.
School-based suicide education programs can have a significant impact on adolescent
difficulties at the microsystem level. The Centers for Disease Control and Prevention (1992) has
recommended school personnel be trained in suicide prevention. Goldman and Beardslee (1999)
noted that open communication and early identification are crucial in the prevention of suicide.
The Turning Hour Project heightens the school staffs' awareness of adolescent issues and opens
a door for connection.
In the same way that the project introduced ontogenic risk factors for discussion in the
classroom, it also provides a natural opening for discussion of microsystem issues. In the novel,
Bergin Talbot and her therapist talk at length about school performance and relationships with
family and peers. One hope for this literature-based approach to suicide education is that it will
allow more open and extensive discussion of these issues between teachers and students.
Viewing suicide as a multi-faceted, human problem (Shneidman, 1985), this approach may
provide a more natural invitation for discussion than presentations by mental health experts
One aim of the Turning Hour Project is to foster a sense of connection among peers,
thereby, reducing the level of loneliness that can occur in adolescence. If peers are able to talk
more candidly--inspired by the voices of the characters in The Turning Hour--perhaps a number
of them will begin to realize they are not alone in their sometimes painful thoughts and feelings.
Ayyash-Abdo (2002) defines the exosystem as the level "of settings in which adolescents
do not play a direct role but nevertheless affect them" (p.465). She uses media as an example of
a primary example of influence in the exosystem. Ayyash-Abdo cites research that links media
coverage of suicide to an increase in suicide rates. High profile suicides have been correlated to
increased suicide rates among adolescent populations. Overall, studies have shown that young
adults are more sensitive to the effects of the duration and prominence of media coverage of a
completed suicide (Gould, 2001; Schmidtke and Schaller, 2000; Stack, 2000).
School-based suicide education programs may these effects of the media through frank
conversations led by responsible adults. As an inoculation against thoughtless media coverage,
suicide can be de-romanticized. Suicidal teenagers can be reframed, as individuals in great pain.
Getting help and finding other ways to relieve the pain can be offered as preferred solutions.
The final level in the ecological approach to suicide is the macrosystem, which Ayyash-
Abdo's (2002) define to include the larger culture influencing the individual. She includes
cultural and ethnic differences in the macrosystem. One of the most significant observed
macrosystem differences is the higher suicide rate among Caucasians adolescents than among
other groups. Ayyash-Abdo focuses on research specifically addressing the difference in suicide
rates between Caucasian and African-American adolescents. She discusses possible reasons for
the difference, citing two major conceptual explanations.
The first is internal/external restraint theory proposed by Henry and Short (1954). This
theory suggests that Caucasians are more likely to feel guilt and blame themselves for failures,
thereby internalizing the cause of their pain. On the other hand, African Americans tend to
blame others for their struggles, externalizing their anger and pain and decreasing their
likelihood to see suicide as a sensible solution.
The second explanation cited by Ayyash-Abdo for the lower rates of suicide in African
American youth is a greater sense of connectedness within the culture. For example, religiosity
is highly valued and the church provides a strong social support system. Also, the African
American elderly tend to live with their extended families rather than move into retirement
communities or nursing homes. This allows them to take a major role in caretaking for the youth
in the family. Religion and family connectedness are identified as significant cultural values in
the African American community. A greater general sense of communalism encourages
individuals to share their concerns and seek help from their support system. These
characteristics have been seen as protective factors against suicide.
In general, family cohesion has been reported as a protective factor for suicidal behavior
among adolescents (Grholt, et al., 2000). For instance, Harris and Molock (2000) examined the
association between family cohesion and suicide by surveying 188 African American
psychology students at a historically black college and found that higher levels of family
cohesion and family support were associated with lower levels of suicidal behavior. In a
longitudinal study of depression and suicidal ideation in adolescents, Garrison, et al., (1991),
surveyed 1,073 middle school students over the course of 3 years and also found that family
cohesion was a significant protective factor against suicide.
Goldman and Beardslee (1999) discuss the importance of family support in their chapter
on suicide in adolescents. They note that the stressors on families can create a crisis situation in
which children are neglected as the focus of parent shifts toward resolving whatever the external
concerns may be. For example, if a parent loses ajob and the family falls into a financial crisis,
the family naturally focuses on ways to pay the bills and survive financially. The focus may be
shifted away from the children, significantly, at a time when they need attention the most. This
decrease in support and supervision can lead to feelings of hopelessness and helplessness in
From this viewpoint, diminished family support can be understood both at the microsystem
and macrosystem levels. At the microsystem level, an individual family can provide less support
for its members than other families in that culture. At the macrosystem level, within an entire
culture, more or less family support can be offered than among other cultures. That level of
support can also change over time, for better or worse.
The sociologist Emille Durkheim developed a theory of social integration. His theory
proposes that individual psychopathology is actually more a result of social dynamics than of
personal, psychological factors. In his book, Suicide, Durkheim (1966) theorizes that suicide is
triggered by a general erosion of societal integration.
Caplan's (1964) focus on the influence of family, friends, the community and the nation-
and his intention to increase supportive response at any of these levels-is also consistent with
the ecological model. As discussed at a number of points previously, The Turning Hour
curriculum provides teens with an opportunity to connect with their classmates, teachers and
school counselors through discussions about the book characters' choices, literary activities and
journal writing. In addition, a letter was sent to parents during the pilot-event before adding the
more elaborate consent form required for this study. This was not only for the purpose of
informing the parents of the curriculum and that their child would be discussing suicide in the
classroom. The letter was also intended to encourage communication between parents and their
teens about suicide.
The hope of the project's creators has been for the community as a whole to engage in
more conversations around the issue of suicide, fostering a sense of connectedness and thereby,
decreasing the likelihood of suicidal behavior. Impacting genuine macrosystem level change
may be an unlikely outcome. Yet, where such change does occur, it is often as a genuine local
The impact of the Turning Hour Project will be measured in very specific ways by this
study (that is, knowledge about adolescent suicide warning signs, attitudes towards help-seeking
with a suicidal peer, and self efficacy in help-seeking behaviors when approached by a suicidal
peer). These are all measures of individual competence. Future studies might also attempt to
measure systemic changes directly. However, the ecological model would suggest that efforts to
impact the various levels of the system would be the optimal way to bring about individual
change, as well.
Bibliotherapy as a Development Guide
A review of trends and some differences in approaches to educational bibliotherapy will
provide another context for understanding the goals of the Turning Hour Project. Many
educators believe literature is an effective tool for helping adolescents cope with life challenges.
The characters offer teens a voice through which they can hear their own feelings of anxiety,
desperation and emptiness expressed. Books may help teens feel less alone, as they realize
someone else understands and is able to verbalize their own response to a situation (Pardeck &
Herbert (2000) proposes two categories regarding the use of bibliotherapy: clinical
bibliotherapy and developmental bibliotherapy. Clinical bibliotherapy refers to a
psychotherapeutic tool used by mental health practitioners in working with their clients.
Developmental bibliotherapy refers to the use of literature as a means to help children learn to
navigate changes in their lives and develop a repertoire of healthy coping strategies.
Developmental bibliotherapy can be conducted by teachers who are willing to have
meaningful discussions about problems in children's lives. Herbert writes, "one advantage of
this approach is that teachers can identify the concerns of their students and address the issues
before they become problems, helping the students move through predictable stages of
adolescence with knowledge of what to expect and examples of how other teenagers have dealt
with the same concerns"(p.2). For the purposes of this paper, bibliotherapy will refer to the
developmental bibliotherapy definition.
More Informational Approaches
In the literature of this developmental bibliotherapy field, there often appears to be a
cognitive emphasis on providing information and helping students learn more concrete solutions
to problems. Pardeck (1994) states this perspective fairly clearly as he provides specific goals
for educators to follow when offering bibliotherapy:
(a) to provide information about problems, (b) to provide insight into problems, (c) to
stimulate discussion about problems, (d) to communicate new values and attitudes, (e)
to create an awareness that others have dealt with similar problems, and (f) to provide
solutions to problems (p.1).
These goals are guidelines for conducting literature discussions and choosing appropriate
books for adolescents to address life events. Through the process of reading the book and
participating in an ongoing discussion, adolescents begin to make sense of their reactions
towards a particular topic. As they hear other voices echo their own thoughts and provide new
ones, the minds of teens expand to learn healthy ways to cope with stressors.
For example, a book chosen to discuss an issue with adolescents about the death of a friend
can provide information about the problem. A book about a friend's death to cancer might
describe a type of cancer and some details about treatment and prognosis. Follow-up discussion
of the book creates an opportunity for the teacher or counselor to present still more information.
Armed with all this knowledge, teens can begin a meaningful discussion of the problem. This
conversation draws in the adolescents, helping them look at the problem through various lenses.
By listening to their peers and teacher, teens learn that there is more than one solution to a
Also presented with more cognitive language, Tussing and Valentine (2001) studied the
use of bibliotherapy among adolescents whose parents have a mental illness (modeling their
research study on a previous study by Sargent, 1985). The authors looked at literature as a
potential tool for helping this population cope with their difficult situation. A non-quantitative
case-study approach explored which books (published between 1985-1999) might be the best
bibliotherapeutic resource for juniors and seniors in High School having a parent with a mental
illness. The researchers decided upon books that gave appropriate information and explanations
regarding mental illness, accepted surrogate parenting, presented positive coping skills and
depicted healthy relationships.
Cartledge and Kiarie (2001) present a model for helping children develop social skills
through the use of literature. They encourage teachers to choose simple books with
straightforward lessons that carry clear messages regarding problem-solving, gender issues,
diversity and respect. Cartledge and Kiarie's model describes how to develop a lesson plan to
teach a particular social skill. The components of this model include; identifying the skill
students are to learn, helping students understand the story concepts, connecting the storyline to
the skill and transferring the knowledge of the skill into action (e.g., with role-plays). The
authors assert that "social competence is predictive of school and later life success" (p. 47).
Maich and Kean (2004) also encourage the development of social skills through
bibliotherapy in their article, "Read Two Books and Write Me in the Morning." They discuss the
changes in society and consequently, a redefining of teachers' roles. It is their belief that
teachers are now charged with character and moral development as well as academic learning.
Maich and Kean (2004) observe that children are more willing to talk about themselves and their
ideas indirectly. They believe books give children a voice through the experiences of the
characters in the story.
More Emotionally Focused Approaches
In this shift toward an emphasis on social skills, the language of some bibliotherapy
proponents begins to move away from more definite, informational perspectives toward more
fluid, process-oriented understandings. The potential of bibliotherapy to help students work
through emotional challenges and find their own solutions to ambiguous dilemmas is suggested.
For example, in a discourse on how literature can help gifted children in particular cope with life
stressors, Herbert (2000) criticizes the frequently limited treatment of gifted children as one-
dimensional. Their intellect is their obvious strength and the focus of the academic curriculum.
Herbert writes that gifted children's emotions are often ignored because the children are
perceived as "smart" enough to handle life's problems and not get into trouble. Herbert sees
literature as one means used to alleviate the actual isolation that this population may often feel.
Books are a creative and non-threatening way to attend to their emotions and the possibility that
they may face issues similar to other teenagers. Herbert describes literature as creating a balance
for gifted teens, between their high intellectual abilities and their high levels of sensitivity
Herbert describes her experience with bibliotherapy in the classroom this way; "Over the
years it has become clear that my student colleagues often use young adult novels as a way of
confronting the issues in their young lives. By sharing their concerns... students not only search
for solutions within themselves, but through their products, create an avenue for others to join in
the therapeutic discussion" (Herbert, 2000, p. 3). With this language, the line between clinical
bibliotherapy as a psychotherapeutic tool and developmental bibliotherapy as a means to help
children navigate changes in their lives becomes even less clear.
In the last decade, there has been some interest in bibliotherapy as a tool to develop
emotional intelligence (Salovey & Sluyter,1997). This idea may help to clarify the goals of
developmental bibliotherapy. It is connected to Daniel Goleman's best-selling book, Emotional
Intelligence (1995). In this book, Goleman expands the traditional definition of intelligence to
include emotion. He gives an example of how students who do not score well on the math
section of a standardized test may not become mathematicians. However, they may easily
succeed in business or politics because of other qualities. Goleman defines these "other
characteristics" as emotional intelligence; "abilities such as being able to motivate oneself and
persist in the face of frustrations; to control impulse and delay gratification; to regulate one's
moods and keep distress from swamping the ability to think; to empathize and to hope" (p. 34).
Following this theory, one can deduce that, in general, children need to develop emotional
intelligence in order to navigate life successfully. Although perhaps controversial, general
emotional competencies may eventually be considered a staple of classroom learning,
In line with this movement, Tang (2002) studied the effects of a bibliotherapy-based
classroom guidance curriculum on children in fourth grade, in a suburban district in Taiwan.
Tang used Lazarus and Folkman's (1984) transactional model of stress as her theoretical
framework. Tang notes that in the transactional model of stress, coping is defined as "constantly
changing cognitive and behavioral efforts to manage specific external and/or internal demands
that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman,
The students read stories that emphasized social-emotional characteristics such as peer
relationships and self-worth. After reading aloud, the students were asked to reflect on their
reading through several forms of feedback (e.g., role-playing, journal writing, group discussion,
creative writing, drawing and individual reflection). The researcher chose to study one class for
one full academic year. The researcher and the teacher collaborated to lead the classroom
discussions. The researcher mentions that in this year, one of the student's fathers committed
suicide. As a result the teacher, school principal and researcher altered the literature program to
include a section called "Live a meaningful life" (p.2).
Three types of information from the students were collected: in-class field notes, semi-
structured interviews and portfolios. By using these three forms of feedback, the researcher was
able to develop a social-emotional skills training curriculum of twenty topics for teachers to use
in their classrooms. Each topic includes a selection of corresponding books, poems and
videotapes. Examples of topics developed are as follows; "How to Deal with Your Anger, Be an
Active Problem-Solver, Understand Your Parents, To Change or Not to Change" (p.5).
The Turning Hour Project
Like most of the programs reviewed in this section, The Turning Hour Project actually
incorporates some focus on helping students develop more tangible coping skills and some focus
on helping them work through more ambiguous emotional difficulties.
Taken as a whole--with the traditional suicide presentation--The Turning Hour Project
provides definite information concerning warning signs about suicide. It offers at least one
definite coping strategy to be learned and incorporate--that is, if you or a friend are considering
suicide, get help. At the same time, it emphasizes a process of approaching taboo, emotionally-
charged subjects-not so much to be taught straightforward lessons about how to respond or
what to believe-but to work through the intense emotions toward some resolution that allows
the individual to stay engaged in living.
Bibliotherapy and Empirical Evidence
While the values of bibliotherapy are a widely accepted tool among school communities,
there is a dearth of empirical evidence that literature actually helps people cope with emotional
concerns, either in educational or therapeutic settings (Corr, 2003-2004). Publications that do
exist tend to be more conceptual and theoretical, with a fairly limited empirical basis, at best. In
his analysis of adolescent literature regarding bereavement issues, Corr (2003-2004) expresses
disappointment at the lack of formal studies that exist in this area. Corr expresses particular
disappointment that more emphasis has not been placed on discovering the actual impact of
bibliotherapy on participants' experiences with emotional difficulties.
While there is an unfortunate lack of empirical research in the area of bibliotherapy,
teachers, librarians and mental health providers believe bibliotherapy in the classroom is making
a difference for the children they work with. The majority of the writings found on this topic
observe that bibliotherapy is a useful intervention that quickly engages children and opens a door
for their feelings, thoughts and ideas. Additionally, bibliotherapy does not require the presence of
a school counselor. It can be facilitated by an insightful and competent teacher. In a world
where school counselors do not have the time or resources to attend to every child equally,
teachers who develop a successful bibliotherapy program appear to be giving the children and
the school an enormous gift. The current research on The Turning Hour Project will attempt one
small step toward providing evidence that bibliotherapy can help students take definite steps
toward dealing more effectively with an emotionally difficult issue.
Suicide Prevention/Education Programs
Suicide prevention programs gained popularity in the 1980s when the problem of adolescent
suicide reached its height. Youth suicide rates had increased over 200% from the 1950s to the
late 1970s (American Association of Suicidology, 2004). There were 16,584 reported adolescent
suicide deaths (ages 15-19) from 1981-1989 (American Association of Suicidology, 2004). And
Garland et al. (1989) reported that the number of schools implementing prevention programs
increased from 789 to 1,709 between 1984 and 1986 (Mazza, 1997).
Prevention programs are curriculums developed to reduce risk factors, such as
disconnection and peer pressure and to enhance protective factors (i.e. communication and
increased self esteem). Kalafat (2003) describes prevention programs as either categorical or
general. Categorical programs focus on a specific issue, such as drug use prevention. General
prevention programs promote healthy attitudes, which translate into coping strategies to help in
many difficult situations.
In 1999, the Prevention Division of the American Association of Suicidology developed
guidelines for school-based suicide prevention programs. This division identified 3 types of
prevention strategies. These are Universal, Selective, and Indicated.
Universal prevention programs are targeted towards the general student population.
These programs intend to develop or enhance the connection between students, their peers and
school personnel. Universal programs focus on increasing students' protective factors. Protective
factors included in prevention programs are; "...problem solving ability; contact with caring
adults; and a sense of connection with school, family, and community based opportunities to
participate and make contributions" ( Kalafat, 2003, p.1212). Universal prevention programs
develop character building skills or coping skills (AAS Prevention Division, 1999). For
example, the Zuni Life Skills Training Program is a program used with the Zuni Pueblo and
Cherokee Nation programs for adolescents. The goal of this program is to teach social skills and
life competency abilities that are necessary for successful social and academic interactions (Doan
et al., 2003).
The AAS guidelines (1999) offer empirically based reasons why universal programs can
be effective in the school system. One of these reasons is that suicidal adolescents are more
likely to confide in their peers than tell an adult (Kalafat, 1992, Zimmerman, 1994).
Additionally, the AAS guidelines report that "as few as 25% of peer confidants tell an adult
about their troubled or suicidal peer" (1999). The guideline suggests that research shows
connecting a suicidal teen to an adult can serve as a protective factor.
Selective Suicide Prevention programs target students who have not specifically
demonstrated suicidality but who may be generally vulnerable, marginalized or at risk. They may
have gone through transitions such a changing schools or divorce. These adolescents will have
been identified through a screening instrument or communication with parents, school
counselors, teachers, other school personnel or their peers. A type of program commonly
referred to as "gatekeeper training" is often used to train school personnel to work effectively
with a specific population of children (AAS Prevention Division). For example, Pam Harrington,
who lost her 15 year old daughter to suicide in 1997, along with other Suicide Survivors have
developed a gatekeeper training, Florida Youth Suicide Prevention Gatekeeper Training
Program. This program has been adopted by The Florida Task Force on Suicide Prevention and
the National Suicide Prevention Strategy, a government task force, in order to teach teachers,
school nurses, school personnel, police officers, mental health care providers, and emergency
health care personnel and other adults who interact with young people how to respond to a
suicidal teen (The Beth Foundation, Inc. 2002). This training as well as other gatekeeper
training allows those who come in contact with children to feel more confident in identifying
warning signs and responding adequately (Davidson & Range, 1999).
Another type of selective prevention resource offered to students is crisis hotlines. These
crisis lines provide twenty-four hour phone counseling to anyone in need. A student who is in
crisis or thinking about suicide can anonymously call the hotline and speak to someone who
offers care and concern and is trained to listen and discuss possible resources or alternatives to
suicide. The AAS prevention guidelines suggest that generally at-risk students may use crisis
lines more than other resources.
The third type of suicide prevention program mentioned in the AAS guidelines is Indicated
Suicide prevention programs. The goal of this type of program is to specifically target suicidal
teens, or teens that have demonstrated specific warning signs of suicide (drug abuse, suicidal
thoughts, previous attempts, depression) and to increase their protective factors. Indicated
programs are run by professionals trained to screen students. These programs are offered by
community-based agencies as well as by school counselors or psychologists (AAS Prevention
The AAS School-Based Suicide Prevention Guidelines specify a number of requirements
for an effective intervention program. The program should have (1) conceptually and
empirically grounded goals, (2) clearly articulated and packaged components and (3) appropriate
instructional principles. It should be (4) comprehensive-addressing all levels of targeted
organization (this means consultation and training should be provided for school personnel as
well as students). It should be (5) a good ecological fit-adapting to the specific and multiple
contexts in which participants interact, and conforming to context/culture/values of the target
population and organization.
The Turning Hour Project
The Turning Hour Project addresses all these AAS criteria. This paper has elaborated the
conceptual grounding for the goals of this project within three areas-crisis theory, the
ecological model and bibliotherapy. General empirical support for these goals has been
elaborated throughout the paper. Beyond that, the goal of this research is to provide empirical
evidence to support this specific methodology.
The components of the Turning Hour Project are clearly articulated and packaged in the
Educators Guide. The instructional principles of the project were developed by a team of
experts in Language Arts and Mental Health issues, within the Alachua County School system,
and refined in consultation with suicide prevention experts from the Alachua County Crisis
Center. The intervention is comprehensive. Before classroom instruction begins, training for
participating teachers and guidance counselors is provided by the creators of the Educators
Guide and staff of the Alachua County Crisis Center. Parents are also notified that suicide will
be discussed in their children's classroom and provided with resources to learn more about
The project is adapted to fit the local ecology at multiple levels. While this program is a
suicide prevention strategy, it has also been designed to fit educational goals mandated by the
public school system in Florida. Educational tasks assessed by the Florida Comprehensive
Assessment Tests (FCAT) are specifically addressed in the goals of lesson plans in the
Educator's Guide (Appendix F).
The Turning Hour Project is ecologically adapted in another fairly sophisticated way. The
Turning Hour Project works in close conjunction with the local, Alachua County Crisis Center
(ACCC). The project provides both students and teachers and guidance counselors with quality
information about suicide prevention. It personalizes the existing relationship between the
ACCC and the Alachua County Schools. It provides students and staff with information about
other local mental health resources and the national suicide prevention hotline. At the same
time, the Turning Hour Project addresses suicide through various lenses. It frames suicide as a
human problem and prevention as a human response. It is thus able also to draw upon resources
from the language arts programs, including the ability of these instructors to engage students in
addressing difficult human issues.
The Turning Hour Project incorporates elements of Indicated, Selective and Universal
prevention. At the Indicated level, the project reinforces awareness of the existing contract
between the Alachua County Schools and the Alachua County Crisis Center-to respond
whenever an individual student is identified as suicidal or concerning warning signs are
observed. That individual will be referred to the Crisis Center for individual treatment. Training
will help teachers understand suicide, know the signs to watch for and have a plan of action if
they see that a student is at risk for suicide.
At the Selective level, The Turning Hour Project increases awareness of risk factors that
make adolescents vulnerable in general. The project is intended to decrease taboos surrounding
many of these difficult issues and to make it more likely that vulnerable students will be able to
get support from peers and to be referred to a qualified adult when appropriate. The project is
also intended to increase the likelihood that students and teachers and students and parents will
talk about these painful issues more freely and genuinely, decreasing the isolation which can
The Turning Hour Project is primarily a Universal prevention program. The previous
three sections of this chapter have detailed the coping skills and protective factors that this
project is intended to model and strengthen. It is intended, generally, to strengthen connection
among students and between students and adults. It is intended to teach a process of navigating
taboo subjects and intense emotions, experientially.
There is another, empirically supported school-based prevention project which appears to
have share a similar essential philosophy. Aseltine & DeMartino (2004) examined the
effectiveness of a school based suicide prevention program called Signs of Suicide (SOS). This
program combines a suicide awareness program with a suicide screening tool. Students are
taught to recognize the signs of suicide and they are taught specific steps to use when faced with
a suicidal peer. The steps are summarized through the acronym- ACT. "First, acknowledge the
signs of suicide that others display and take those signs seriously. Next, let that person know that
you care and that you want to help. Then, tell a responsible adult" (p.446). The researchers
surveyed twenty-one hundred students through the use of self-administered questionnaires three
months after the participants received the prevention program and found significantly lower rates
of suicide attempts, greater knowledge and more adaptive attitudes about depression and suicide
in the students in the intervention group.
The traditional suicide prevention component of the Turning Hour offers a model of peer
based crisis response that is very similar to the three steps of ACT. The most difficult of these
steps to teach in a short intervention is probably the second step. The Turning Hour Project is
intended to emphasize all three components of this response. But its greatest strength may be its
emphasis on caring--on providing students with an increased ability to demonstrate this empathy
The purpose of this quasi-experimental study was to determine the effectiveness of the
Turning Hour Project, a suicide education program developed for high school students to
increase the level of suicide prevention knowledge. Students' attitudes towards suicidal peers
were also examined.
The following topics are covered in this chapter: (1) sample characteristics, (2) variables,
(3) instrumentation, (4) null hypotheses, (5), research procedures, (6) data collection and analysis
and (7) methodological limitations.
Over 700 surveys were collected for this study. Many of these surveys could not be
included in the statistical analysis due to unplanned scheduling changes that were inconsistent
with the study design. The analyzed sample consisted of 154 participants (79 male, 73 female
with two participants not indicating their gender) with a mean age of 15.58 (SD =1.15). The
sample was primarily Caucasian, 66.4% (N= 101), followed by African American, 14.5% (N
22), Multiracial, 8.6% (N= 13), Hispanic/Latino 6.6% (N= 10), Other 2.6% (N= 4), Asian
American, 0.7% (N = 1), and Native American, 0.7% (N = 1).
Participants were asked to indicate their year in high school, which consisted of primarily
9th graders, 46.1% (N= 71), followed by 10th graders, 30.5% (N= 47), 11th graders, 11.7% (N
= 18), and 12th graders, 11.7% (N= 18). The classes ranged from Advanced English to Regular
English, all students were required to read The Turning Hour alternating between class time and
Three schools are in Gainesville, Florida (Gainesville High School, W. Travis Loften High
School and F.W. Buchholz High School) and three are in rural areas of Alachua County
(Newberry High School, Hawthorne High School and Santa Fe High School). Twelve teachers
participated in this study along with the students in their classes. Four of these teachers allowed
the Crisis Center staff to come into their class and deliver the presentation on suicide prevention
(Group 1). Another four taught The Turning Hour as part of their curriculum and had the Crisis
Center give their presentation on suicide prevention (Group 2). The last four teachers
participated as the control group for this study. The students participating in this study live,
primarily, in Alachua County, which is considered a rural county with the exception of
Gainesville, Florida. Gainesville is described as an "Urban Fringe of Mid-Size City" by the
Public School Review website (Public School Review LLC, 2003).
The schools in Alachua County are racially diverse with primarily African American
(29.17%) and Caucasian (62%) populations. The students in these high schools range from
upper middle class socioeconomic status to poverty level. Three of the high schools are in
Gainesville, Florida, which is commonly referred to as a university town because the main
campuses of the University of Florida (UF) reside within the city limits. Approximately fifty
thousand students attend the University of Florida and a majority of these live in Gainesville.
The high schools within Gainesville, Florida are influenced by the University of Florida in
numerous ways. Many of the university's faculty and staff enroll their children in these schools.
Also, the university collaborates with the Alachua County School Board to offer innovative
programs to the students. An example of this is UF's department of Astronomy, who offers a
space education program to students of varying grade levels.
The first independent variable in this study was The Turning Hour school-based suicide
education program. A second independent variable in this study was the suicide
prevention/intervention presentation given by a staff member at the Alachua County Crisis
Center (ACCC). The following dependent variables were measured by the researcher:
1. Students' degree of knowledge regarding adolescent suicidal warning signs.
2. Students' attitudes towards help-seeking and intervening with a suicidal peer.
3. Students' degree of self-efficacy in help-seeking behaviors when approached by a
Warning Signs are behaviors that researchers have documented in individuals who have
completed suicide. An example of a warning sign is giving one's beloved possessions away.
This study attempted to measure the effect of The Turning Hour suicide education curriculum on
the students' recognition of warning signs. In this study, recognition of warning signs was
measured by the Lifelines Questionnaire (Kalafat & Elias, 1994).
Attitudes towards helping a suicidal peer is defined as an individual's willingness to listen
to their peer and help get them connected to the appropriate resources. As mentioned in chapter
1, studies (e.g., Kalafat & Elias, 1994) have shown that teens are reluctant to tell an adult about
their suicidal friend. An emphasis of this program is to facilitate conversation between the
students and various adults (teachers, counselors and crisis center staff). This study attempted to
measure the students' attitudes towards help-seeking behavior using the Lifelines Questionnaire
(Kalafat & Elias, 1994).
Self-efficacy is defined as an individual's perceived ability to complete a task or perform a
behavior successfully. The Turning Hour Project hopes to enhance students' perceived ability to
help suicidal friends in need. The project focuses on teaching students about suicide,
communicating directly and honestly and helping teens get help from appropriate resources.
This study measured self -efficacy using the Lifelines Questionnaire (Kalafat & Elias, 1994).
One questionnaire was used for data collection. A personal data sheet was distributed and
used to obtain demographic information from the participants. Additionally, a feedback sheet for
the students regarding The Turning Hour Project is included with the final survey.
The Lifelines Pre/Post Questionnaire (LQ) (Kalafat & Elias, 1994) is a 30-item, self-
reporting instrument that provides quantitative data about high school students' responses to
Lifelines, a school-based suicide awareness program. (Appendix C) This questionnaire was
developed by Drs. John Kalafat and Maurice Elias in order to test the efficacy of Lifelines, a
suicide prevention program developed by John Kalafat and Maureen Underwood in 1989.
Similar to the Turning Hour Project's central themes, Lifelines' focus is on increasing students'
knowledge about suicide and promoting positive attitudes toward help-seeking and intervening
with suicidal peers. Four domains were assessed in the Lifelines study: knowledge about
suicide; attitudes toward suicide, help seeking, and talking about suicide in one's classes; self
reported responses to the awareness of potential suicide in peers; and, reactions to the suicide
awareness classes (Kalafat & Elias, 1992). The scale was given to 253 10th grade students in a
northeastern community, in the United States, who participated in the Lifelines curriculum. In a
report of their findings, Kalafat and Elias describe the development of the Lifelines
questionnaire. The authors note that "in order to insure fidelity to the curriculum content and
comparability with other studies, items from this questionnaire were drawn from published
curriculum assessment instruments (Shaffer, Garland, & Whittle, 1988; Spirito et al., 1988) and
from a pool of items developed by the health teachers..." (Kalafat & Elias, 1994, p. 227). The
health teachers were the instructors for the Lifelines curriculum and developed items for the
suicide awareness classes as they would for any other unit.
The purpose of this study was to determine whether the Turning Hour Project has an
impact on high school students' awareness, attitudes and help-seeking behaviors regarding
suicide prevention. The Lifeline questionnaire assesses these three variables.
The items in the Lifeline questionnaire are divided into 5 sections. The first section
consists of two scenarios that assess self-reported responses to awareness of potential suicide in
peers. These questions ask the students to describe how they would respond to a suicidal peer
that confides in them. The responses will reflect the attitudes each participant has towards
In the following four sections, students are asked to rate on a 5-point summary scale
whether they agree or disagree with each item. End points of the scale are 1-Strongly Agree-
to 5-Strongly Disagree. Higher values indicate more adaptive attitudes about suicide and help-
seeking intervention. The second section is made up of 10 items assessing the students' self-
reported attitudes towards suicide. The third section of the Lifelines questionnaire consists of 8-
items that assess the students' suicidal behavior (warning signs) knowledge. The fourth section
consists of 5-items that measure a student's attitudes towards their self-efficacy and potential
resources if they need to seek help for a suicidal friend. Finally, the last section of the
questionnaire has 5-items assessing a students' willingness to seek an adult to help their friend.
The construct validity of the instrument was examined using factor analysis. Based on the
factor analysis, the four factor solution explained 49% of the variance. Analyses of the interitem
covariances indicate the factors were internally consistent This measure has shown reliability
with Chronbach's reliability coefficients for each subscale, as follows; Knowledge, 0.89;
Attitudes, 0.80; Help seeking, 0.76; Awareness, 0.77 (Kalafat, J. & Gagliano,1996). Permission
from the authors has been obtained to use this scale in this study.
Personal Data Sheet
A personal data sheet was distributed to all participants to obtain demographic data.
(Appendix B) The students were asked to give information about their age, school, grade, sex,
race and any previous suicide prevention training.
The following null hypotheses were investigated:
Hol: There will be no significant difference in knowledge of suicidal behavior between
the groups of students based on their participation in the suicide prevention program.
Ho2: There will be no significant difference in attitudes towards help-seeking and
intervening with suicidal peers between the groups of students based on their
participation in the suicide prevention program.
Ho3: There will be no significant difference in students' degree of self-efficacy in suicide
related help-seeking behaviors when approached by a suicidal peer between the groups of
students based on their participation in the suicide prevention program.
All English teachers and guidance counselors from Alachua County High Schools were
invited to participate in the Turning Hour Project. Twelve teachers and their respective guidance
counselors agreed to participate in this study. Approximately, 200 High school students
participated in the study. Participating teachers and guidance counselors received training on
January 19th, from 8:30am-3:00pm, 2006. The training was conducted by Mary Anne Wagner
and Diane Heaney.
Mary Anne Wagner is the Supervisor of Language Arts and Reading for Alachua County
School Board. She also has a specialist degree in guidance counseling. Ms. Wagner has headed
the development of The Turning Hour curriculum and has taught the course several times to gain
first hand knowledge of how it can be improved. Diane Heaney is a consultant who supervises
secondary teachers who participate in a practicum related to reading endorsement. She is a
former elementary classroom teacher and adult education teacher.
All teachers and guidance counselors who agreed to participate attended the training
session prior to beginning The Turning Hour curriculum. Each teacher received a packet
including the 8-unit lesson plans, 35 paperback copies of The Turning Hour, an Educator's
curriculum guide, a cover letter describing the study, consent forms for the students and consent
forms for the parents. The training session included the following components: introduction to
The Turning Hour by the author, Shelley Fraser Mickle, through a video presentation; overview
of each lesson plan in The Turning Hour Educator's guide, instruction on the most effective
methods to teach students to journal including discussion on teacher feedback that elicits more
developed journal responses; a presentation by the local suicide prevention experts (Alachua
County Crisis Center) which discusses the material presented to students and provided teachers
with an opportunity to discuss their own concerns or questions regarding adolescent suicide.
Following the training, the teachers' participating classes were divided into two groups.
Group 1, received the suicide intervention/prevention presentation from a staff member of the
Alachua County Crisis Center. Group 2 completed The Turning Hour unit and then also
received the suicide intervention/prevention presentation. Both groups received the Personal
Data Sheet and the Lifelines Questionnaire pretest and posttest. All teachers were visited by the
Turning Hour trainers, at least twice, as they facilitated the program in their classrooms.
Suicide prevention programs typically include the information (statistics, warning signs
and resources) that was provided by the ACCC staff. The unique piece to this program is The
Turning Hour curriculum. The design of this study allowed the researcher to test for significant
differences between groups who received only the didactic presentation and those who received
both interactive and didactic interventions. The goal of this design was to see if The Turning
Hour curriculum lends power to the suicide intervention presentation or makes the curriculum
The Suicide Prevention/Intervention Presentation was conducted by the Alachua County
Crisis Center (ACCC) staff members Dana Myers and Alexandra Martinez. Ms. Myers is a
licensed Mental Health counselor and a member of the American Association of Suicide
Prevention. She is the Training Coordinator for the ACCC and has been with the center for over
10 years. Ms. Martinez is a licensed Marriage and Family therapist. Presently, she is the Project
Coordinator for the ACCC. She has worked as a therapist and Child Advocate for 5 years. Both
presenters are graduates of the University of Florida's Counselor Education program.
Data Collection and Analyses
The design for the study is shown in Table 3-1. All participating students received a
Personal Data Sheet to complete prior to beginning any treatment.
Group 1 received the pretest two weeks prior to the presentation from the Alachua
County Crisis Center staff. The purpose of this interval was to create an equal time difference
between interventions: 1) the ACCC presentation and 2) the combined ACCC presentation and
Turning Hour curriculum. The Alachua County Crisis Center presentation included adolescent
suicide statistics, suicidal warning signs, recommended interventions and information about
resources in Alachua County. Group 1 received the Posttest immediately following this
The second treatment group (Group 2) was comprised of those students who attend class
with the teachers who agreed to participate as facilitators of The Turning Hour curriculum.
Group 2 was given a Pretest on the day they began The Turning Hour Project. Immediately after
Group 2 finished the two week unit, they participated in the same presentation given to Group 1
by the same Alachua County Crisis Center staff person. Group 2 completed the Posttest
immediately after this presentation was given.
Group 3 served as the control group and did not receive treatment between each survey.
Group 3 was asked to complete the survey twice, with time intervals equal to Groups 1 and 2. In
order to provide this group with information regarding suicide awareness and prevention, Group
3 participated in a presentation given by a Staff member from the Alachua County Crisis Center
after both surveys were completed.
This study made use of a quasi-experimental design in which the investigator was
interested in discovering if change over time occurred in students' knowledge, skills and
attitudes regarding suicide prevention while they participated in a suicide prevention course. The
course combined didactic information with an interactive language arts program that addressed
adolescent suicide. A one-way (treatment versus control) analysis of covariance was used to test
for differences between groups, with posttest scores as the dependent variable and the pretest
scores as the covariate. The ANCOVA was used to explore the prediction that the difference in
responding is specifically related to the addition of the Turning Hour curriculum to the suicide
prevention program. For each measure, post hoc multiple comparisons were conducted using the
Tukey HSD Significant Difference Test (familiar and common) method to identify significant
differences among the treatment groups.
Table 3-1. Outline of Research Design.
Pretest Treatment Test 2
Group 1 01 A.C.C.C. + 2 week interval 02
Group 2 01 A.C.C.C + T.H. 02
Group 3 (Control) 01 02
01=Pretest 02=Posttest T.H.= Turning Hour Curriculum (2 week program)
The purpose of this study was to determine the effectiveness of the Turning Hour Project, a
suicide prevention/education program developed for high school students to increase the level of
suicide prevention knowledge. This quasi-experimental study examined the impact of a 2-week
suicide prevention program on high schools students' awareness of suicide prevention, attitude
towards suicidal peers and their willingness to help suicidal peers.
A pre-test-post-test control group design was used. Teachers who agreed to participate had
a choice between three group conditions. Groups were developed based on the teachers' choices.
Data were collected from a survey that included a demographic sheet, and an instrument used to
assess the effects of the study's intervention, the Lifelines Questionnaire. All participants
completed the demographic data sheet. All participants completed the Lifelines Questionnaire as
a pre-test and post-test. Results from the current study are described below.
In order to assess the capacity of the data to be in line with the normality assumptions of
analysis of covariance (ANCOVA), the skewness and kurtosis of the data was examined. This
indicates that the assumptions for normalcy were met. All skewness and kurtosis estimates for
the variables fell between 2 and -2 except for the Knowledge sub scale on the pretest and
posttest, which had a kurtosis value of 3.788 and 4.299, respectively, and the Tell Friend
subscale which had a kurtosis value of 2.939 on the pretest.
Additionally, mean differences were conducted between groups (treatment 1, treatment 2
and control group) to make sure there were no differences in pretest scores. Results indicated
that there were no significant differences between groups on pretest scores (all ps > .05).
In addition, measurement reliabilities for the Lifelines Questionnaire (LQ) pre/posttests
were conducted and reliability coefficients appear in Table 4-1. A 2-week test-retest reliability
analysis was conducted, correlating pre-test to post-test LQ subscale scores for the control group,
with results indicating a moderate magnitude of the coefficients for Help Seeking, r = .42, and
Not Help, r = .53, however, test-retest reliability for both the Knowledge (r = .27) and Tell
Friend (r = .11) subscales were in the low-moderate range. Additionally, Cronbach's coefficient
alpha for the LQ subscales of Help Seeking, .70, and Knowledge, .60, were somewhat lower than
Kalafat & Elias (1994) findings (.89 and .80 respectively). Reliability findings for the LQ
subscales of Not Help, .38 and Tell Friend, -1.74 were substantially lower than Kalafat & Elias
(1994) findings (.76 and .77 respectively) and are well below the acceptable range for reliability,
which is between .50 .90 (DeVellis, 1991). Thus, results regarding the Not Help and Tell
Friend subscales should be considered with caution in light of the low reliability found on these
two subscales in the current study.
Separate univariate analyses of covariance were conducted along each of the subscales of
the LQ (Help Seeking, Knowledge, Not Help, and Tell Friend) with Group (treatment 1,
treatment 2, and control group) as the independent variable, posttest scores as the dependent
variable, and pretest scores as the covariate in each analysis.
The first hypothesis was that both treatment groups (those that received the Crisis Center
training and those that received both Crisis Center training and the Turning Hour Project) would
show increased levels of knowledge (i.e., teens can't do very much to prevent teen suicide) as
evidenced by higher scores on the knowledge subscale of the LQ. Thus, for the first hypothesis,
a univariate analysis of covariance was conducted to determine if the treatment groups revealed
significantly higher scores on the knowledge subscale.
Results from the ANCOVA did not reveal a significant difference between groups along
the Knowledge subscale, F(2, 122) = 1.39, p > .05. This was not in the predicted direction of the
hypothesis. One explanation for this finding not being in line with the initial hypothesis could be
the fact that there was low test-retest reliability for this subscale and somewhat higher skewness,
which may have affected the normality of the distribution.
The second hypothesis was that both treatment groups (those that received the Crisis
Center training and those that received both Crisis Center training and the Turning Hour Project)
would show increased levels of help seeking (It is important to have at least one adult that you
can talk to if something is bothering you) as evidenced by higher scores on the Help Seeking
subscale of the LQ. Thus, for the second hypothesis, a univariate analysis of covariance was
conducted to determine if the treatment groups revealed significantly higher scores on the Help
Results from the ANCOVA revealed a significant difference between groups along the
Help Seeking subscale, F(2, 122) = 7.28,p <.001. Follow-up custom hypothesis testing revealed
a significant difference between treatment 1 (both crisis center and turning hour training) and
treatment 2(crisis center training only), p < .001 and the control group, p < .019. As predicted,
the direction of the differences indicated that the treatment 1 group's scores were higher on the
posttest (M= 41.87, SD = 5.33) than treatment 2 (M= 36.71, SD = 6.40), and the control group
(M =38.71, SD = 5.86) when pretest scores were covaried. There was not a significant
difference between treatment 2 and control group scores, p > .05, which was not in the predicted
The third hypothesis was that both treatment groups (those that received the Crisis Center
training and those that received both Crisis Center training and the Turning Hour program)
would show increased levels of helping a friend who acknowledges suicidal ideation (If
someone really wants to kill themselves, there is not much I can do about it) as well as telling a
friend if they knew another friend had suicidal ideation (tell another friend about what you
notice about your friend), as evidenced by higher scores on the not help and tell friend subscales
of the LQ. Thus, for the third hypothesis, two univariate analyses of covariance were conducted
to determine if the treatment groups revealed significantly higher scores on the not help and tell
Results from the both ANCOVA did not reveal a significant difference between groups
along the not help, F(2, 140) = 1.25, p > .05 or the tell friend subscales, F(2, 139) = 0.30,p > .05.
This was not in the predicted direction of the hypotheses. As suggested earlier, an explanation
for this finding not being in line with the initial hypotheses could be the fact that the reliability
for these subscales was below standards. Additionally, the kurtosis level for the tell friend
subscale was also somewhat higher than usual standards. This will be further discussed in the
limitations portion of this study.
At the most basic level, the results of this study more broadly show the usefulness of the
Turning Hour Project for this population. The most important, tangible goal of this research
project was to provide empirical evidence of the value of the Turning Hour Project value to its
creators. In the zeitgeist of the school systems and the larger contemporary world, this kind of
evidence is all but essential to the acceptance and ongoing use of any methodology.
In this study, student participants in the Turning Hour Project reported a statistically
significant higher willingness to seek help--as measured by an established instrument developed
for a school-based suicide awareness program--than either those students who received a
traditional suicide prevention/intervention presentation or those students in the no-treatment
control group. With this evidence, the supporters of the Turning Hour Project will have a strong
basis to argue for the ongoing use of this methodology and for its dissemination into wider use in
the schools. Given the tremendous face-value richness of the Turning Hour Project, the primary
goal of this study has been met.
Of course, there is room and cause for a great deal more research to be done around this
intervention. The most immediate pragmatic need would be to replicate this study, strengthening
the claim of empirical support. Beyond that, the Turning Hour Project offers a wealth of
possibilities to future researchers.
It is encouraging that the Help Seeking scale did yield a significant measured difference.
However, talking to teachers who administered the Turning Hour Project, it is apparent that a
great deal happened in these classrooms that the Lifelines questionnaire--designed for an entirely
different intervention-was never intended to measure. Optimally, researchers could develop
new instruments, aimed to measure what actually appears to be happening in Turning Hour
Many of the basic ideas at the heart of this project-spelled out in the first two chapters of
this study-would readily lend themselves to measurement. One basic idea is that students talk
more freely about taboo topics when they are presented in the framework of literature and the
human condition than they do when the same topics are presented in a framework of traditional
mental health services delivery. This could be addressed through a rating scale designed for use
in direct observations of classroom interactions.
Another idea is that Turning Hour participants will be able to engage their peers more
appropriately and effectively because engagement is taught experientially through the project
rather than only encouraged didactically in a brief lecture on the value of peer crisis intervention.
This could also be measured readily. Participants in the Turning Hour group and other control
groups could be engaged in helping skill role plays-without any further training-which could
be rated by experienced role play evaluators.
Yet another idea is that the journal component of the project has its own intrinsic value,
potentially helping students work through difficult issues and solidifying new coping skills. This
could be measured by offering two different versions of the Turning Hour Project-one with the
journal component, and another with a more concrete, non-exploratory academic component in
its place. Differences between the two groups could be measured, most easily with a self-report
rating of the overall value of the Turning Hour experience in helping students address their own
Given widespread dissemination of this project, of course, grander measures would also be
possible. Are more at-risk individuals actually identified through this program, in the actual
classrooms during the time when the program is administered or in the year that follows? Do the
student participants in the Turning Hour Project actually facilitate a larger number of
interventions to help their peers during the project or over the course of the following year? Do
the student participants themselves demonstrate any higher levels of adaptive or lower levels of
maladaptive coping skills in the year that follows the program?
All of these quantitative empirical measures would increase our understanding of the
Turning Hour Project. With significant results, they could potentially increase its attractiveness
to school personnel. This research would also contribute to the literatures of crisis intervention
theory, the ecological model of suicide prevention, bibliotherapy and the general literature of
suicide prevention projects.
The richest research of the greatest genuine value to educators and clinicians would be
qualitative and systemic in nature. In the end the goals and theoretical aspirations of this project
are more process oriented than outcome oriented. The goal, for instance, is not only to make the
students speak more often to the adults about their problems. The goal is also help the adults
become more worth talking to. It is to make the conversations that happen of more real value. It
is to change the very nature of the relationships among the students and between the students and
adults in the schools. Whatever their pragmatic, political value--static empirical measures of this
change could not provide the same level of understanding and inspiration that are the real
potential of the Turning Hour Project.
Limitations and Future Research
Assessing suicidal knowledge and attitudes in high school aged students is a difficult
process. Although there are many Suicide Awareness and Prevention programs around the
country, there is little empirical research on their effectiveness. Testing adolescents on their
knowledge of suicide is considered a taboo issue. As mentioned previously in chapter 1,
adolescents do not typically feel safe giving information to adults. Chapter 2 mentions a study
where researchers, Kalafat and Elias (1992), found that 63% of the students tested took it upon
themselves to help a suicidal peer without telling an adult; if this statement is consistent
throughout the population of teenagers, then it can be assumed that adolescents do not feel safe
sharing any kind of compromising information with adults. Thus, the reliability of a survey
completed by teenagers may have been decreased by the notion that they will not consistently
give accurate and comprehensive information to adults. Additionally, since teachers in a high
school setting collected data where there is a high likelihood of teenagers not consistently giving
accurate information to adults and not filling out questionnaires completely, the data collection
procedure may have compromised the external validity of the current study.
The characteristics of participants in the current study may have compromised the external
validity. This study was conducted on a voluntary basis and those who volunteered to participate
may have been a biased sample. Rosenthal and Rosnow (1975) suggest that volunteers tend to
differ from non-volunteers in behavioral research regarding their level of education, intelligence
and desire of social approval.
The original plans for this study included over 700 participants. Many surveys were
thrown out of the data collection because they were incomplete. A large number of surveys could
not be used due to miscommunications regarding the scheduling of the suicide prevention
lecture. These issues resulted in a significantly lower sample size than anticipated for the
groups, which may compromise the representativeness of the sample and generalizability of the
findings. Testing-effects are another limitation to the external validity of this study such that
having a pretest may have sensitized the participants so that they are affected differently by the
intervention (Kazdin, 1998).
In addition, the study that validated the instrument, Lifelines Questionnaire (Kalafat &
Elias, 1992), was conducted with a relatively small sample and has not been replicated.
Although the design has advantages, it also brings limitations. A true experimental design
is not possible because students cannot be randomly assigned to the three groups based
conditions for participation put forth by the schools. The schools did not require teachers to
participate in the project. Therefore, because they agreed to give extra time to this research,
teachers who volunteered were asked to choose which group (Group 1, Group 2 or Control
Group) they would like to be part of based on their comfort and time commitments. Student
participation was dependent on their teacher's decision. Therefore, there are limitations to the
investigator's ability to claim a causal relationship, even with positive results. Using a quasi-
experimental design, this researcher has a responsibility to discuss potential threats to validity.
One possible confound would be the difference between the composition of the classes that
receive the two treatments and those that do not, any differences should be described to the
degree they can be known. Any high profile event (such as a suicide publicized in the national
media) could be expected to affect all the classes in roughly the same ways. However, any event
which affected students differently (such as a suicide attempt known only to students in one
school or a certain social group with higher membership in a particular treatment group) could
create a confound.
As a result of the program, it is quite possible that students talked with other classmates,
friends and family members about their participation in the Turning Hour Project and even
specifically about suicide. This breaking of the taboo could have been a positive effect of the
treatment (much as taking a Selective Serotonin Reuptake Inhibitors-SSRI may have given
individuals energy to make desired changes to resolve difficulties in their lives). Yet, students in
the treatment groups could have also talked to schoolmates in the control group, creating a ripple
effect, which may have weakened the observed statistical difference between the groups.
Another possible limitation of the study was the design for students to take the same
survey twice. This could serve as an advantage because reliability is tested over time with the
use of the same instrument. However, this repeated testing could have been a limitation if
students experienced impatience, answering the same questions two times, and then filled out the
survey less genuinely and accurately.
In addition, internal validity may have been compromised due to history effects (any event
occurring in the experiment, other than the independent variable, or outside the experiment that
may account for the results, Kazdin, 1998). For example, to some extent students in the
treatment groups may have talked with schoolmates in the control group, which may have
affected the results. Additionally, testing effects have to be considered as a threat to internal
validity in that taking the pretest may have affected participant's performance on the posttests.
There are also limitations regarding the reliability of the Lifelines questionnaire due to the
poor psychometrics that this questionnaire revealed (e.g. test-retest reliability and Chronbach's
Alpha). An item discrimination was run with the descriptive information and the original data
was recorded numerous times to determine why the tell a friend and knowledge subscales showed
poor reliability. There was no change from the initial reliability reports. One possible
explanation is misinterpretation of the question due to poor wording. Another is that each of
these items had only three and four questions respectively. Future research should focus on
further refining the psychometrics of this survey.
However, in light of these limitations, the findings of the current study still contribute to
the literature addressing teen suicide prevention. The current study provides provisional support
for the notion that providing the Turning Hour education program increases teenager help
seeking behaviors in regards to suicide prevention.
INFORMED CONSENT FORMS
The Tiiininu Hour Proiect. 2i'
December 12, 2005
I am a doctoral student in the Department of Counselor Education at the University of Florida, conducting
research on the usefulness of "The Turning Hour Project" as a suicide awareness/prevention tool for high
school students. I will be working under the supervision of Dr. Silvia Echevarria Doan. The purpose of
this study is to see if the study of a fiction book that addresses the issue of teen suicide will (1) increase
the high school students' knowledge about suicide as a problem, and (2) increase their willingness to
seek adult help for a friend in need. The results of this study may help us understand the usefulness of this
project and allow us to continue working toward an effective suicide awareness/prevention tool. With
your permission, I would like to ask your child to volunteer for this research, no compensation will be
provided for their participation.
Two-thirds of the students participating will study the novel, The Turning Hour, by Shelley Fraser
Mickle. The instruction will be provided by your child's English or Health teacher. (You will be receiving
a letter from them as well). The school guidance counselors will also be involved in this project. One-
third of the students participating in this study will not study the Turning Hour. All students will receive
a forty-five minute talk on suicide awareness and prevention from a staff member of the Alachua County
Crisis Center. All the students will be asked to fill out a 30 question survey related to suicide prevention.
They will be asked to fill this questionnaire out two times in order to assess their understanding of the
Your child's identii iill be kept confidential to the extent prove ided b thlie la\. Results Aill onI\
be reported in the formni of group datn. Participation or non-participation in this studi %ill not
affect the students' grades or pIaceinent in ann of the prograins.
You and your child have the right to withdraw consent for your child's participation at any time with no
consequence. The issues discussed in class (suicide, teen despair, relationship issues) are serious and can
bring up feelings for your teen. We will be providing information for local resources that can offer help
for any concerns that come up as a result of the study. If you have any further questions about this study,
please contact me at 352-284-1293, or my faculty advisor, Dr. Doan, at 352-392-0731, ext.237. For
questions about your child's rights as a participant, please contact the Institutional Review Board at 352-
392-0433 or firstname.lastname@example.org.
I have read the procedure described above. I voluntarily give consent for my child,
~~~____~~________, to participate in Patricia Xirau-Probert's study
of adolescent suicide awareness/prevention. I have received a copy of this description.
PERSONAL DATA SHEET
Personal Data Sheet
The following questions are intended to gather demographic information about the students
participating in this research study. You will not be asked to identify yourself by name. Your
responses will be reported only in general terms as they relate to relevant variables of interest.
Thank you for your participation!
1. Gender: M F 2. Race (check one): African American
3. Age: Hispanic/Latino/Latina
4. Grade: 9th 10th 11th 12th
6. Have you had peer mediation training? (Circle one) Yes No
7. Have you had any training in suicide prevention? (Circle one) Yes No
8. If you answered yes to question 7, which of the following best describes the type of training
you have had. (Circle one)
Lecture/Presentation in class HotlineTraining Combined lecture/video
9. Do you know anyone who has attempted or committed suicide? (Circle one) Yes No
10. Has a friend ever confided their suicidal thoughts or attempts to you? (Circle one)Yes No
LIFELINES QUESTIONNAIRE AND PROGRAM FEEDBACK FORM
CODE: Today's Date: / /
Name of School:
Sex: Female Male Grade in School:
Have you read The Turning Hour, by Shelley Fraser-Mickle? (Circle one) Yes No
A good friend of yours has seemed troubled lately and has begun to keep more and more to
herself One day you go to see her and she tells you she would like to talk to you about
something, but you must promise to keep it a secret. She seems pretty serious and you value
your friendship with her a lot so you agree not to tell anyone what she has to say. She tells you
that she and everyone else would be better off if she were dead. Then she says, "Sometimes I
think I might as well kill myself'. She smiles and shrugs her shoulders when she says it. She
then reminds you of your promise not to tell anyone. You are the only person she trusts, she
says, and if you tell, she will never forgive you.
How would you respond in this situation?
How concerned would you be?
Not very 0
Not at all 0
You have a friend at school who has been keeping to himself lately. You know he has trouble at
home his parents are getting divorced and he's not sure who he will be living with or if there
will be enough money for him to go to college. It is Friday and you ask him to go to a party with
you but he declines to go.
Later that day in English class, the teacher is reading samples of students' short essays that she
has assigned. She doesn't identify the writer but one of them is entitled "(Final) Family
Decisions" and describes a very important decision that is about to be made by the writers'
parents that will involve whether he will change schools and whether he will be able to go to
college. The writer says that he may not go along with his parents' decision and make one of his
own that will resolve things.
You believe that your friend wrote this essay and that you are the only one who knows what he is
How would you respond in this situation?
How concerned would you be?
Not very 0
Not at all 0
Please fill in the circle that most closely represents what you think about
C-t Q CD
1. Teens can't do very much to prevent teen suicide. 0 0 0 0
S It is important to have at least one adult that you can talk to if
something is bothering you. 0 0 0 0
3 A friend's confidence about suicidal feelings should never be
broken. 0 0 0 0
4 People should be expected to handle all of their own problems
without outside help. 0 0 0 0
5 People who are seriously planning to kill themselves don't want any
help. 0 0 0 0
If somebody wants to kill themselves, nobody has the right to stop
them. 0 0 0 0
7 Teens are at a point in their lives where they should not rely on
adults for help with problems. 0 0 0 0
8 It is not a good idea to ask someone if they are thinking about
suicide because you may give them the idea to try it. 0 0 0 0
9 My school is prepared to help a student who might be thinking about
killing him/herself. 0 0 0 0
If a friend came to school in a bad mood and casually mentioned,
10. "my family would be better off without me", I would encourage him 0 0 0 0
__or her to get help from a responsible adult._________
For questions 11 18 please fill in either True or False for each question True False
11. People who talk about suicide do not commit suicide. 0 0
12. Giving away prized possessions may be a sign that a student is thinking 0 0
13. The fact that a person has attempted suicide means that they are not 0 0
likely to try it again in the future.
14. Suicide attempts are rare among good students. 0 0
15. If a person seems to feel better after they have been feeling really down 0 0
or depressed, they are not likely to try to kill themselves.
16. Suicide tends to "run in families' that is, if someone in a kid's family
committed or attempted suicide, that kid is more likely to commit or 0 0
17. Males commit suicide more often than females. 0 0
18. Most teens who try to kill themselves really want to die. 0 0
0O -t -tS'S'g
For Questions 19 through 23, Please fill in the circle that most closely 8 P
represents what you think about the question. C D
19.. The best thing to tell a suicidal friend is to "pull yourself
together and things will get better". 0 0 0 0
20. If someone really wants to kill themselves, there is not much I
can do about it. 0 0 0 0
21. I know what officials in my school will do if they learn about a
student who is thinking about killing or hurting him/herself. 0 0 0 0
22. There is at least one adult in my school that I could confide in
about a concern of my own or about a friend's concern. 0 0 0 0
23. If a friend told me that she/he is thinking about killing
her/himself, I would not know what to do. 0 0 0 0
For question 24 28, please fill in the circle next to the sentence that most closely represents
how you feel about the question.
If a suicidal friend asked me not to tell anyone, I would:
0 Definitely tell someone
0 Probably tell someone
0 Probably not tell someone
0 Definitely not tell someone
If a friend began to lose interest in activities and friends
and sometimes said things like s(he) wasn't much good to
anyone would you:
a. Mind your own business and let him/her have his/her 0 0 0 0
b. Ask him/her if something was bothering him/her. 0 0 0 0
c. Try to get him/her to go talk to some trusted adult
about what's bothering him/her. 0 0 0 0
d. Tell a trusted adult about what you notice about your 0 0 0 0
e. Tell another friend about what you notice about your 0 0 0 0
Which of the above would you be most likely to do? Write the letter of your choice here:
If a friend told you s(he) was thinking about killing
him/herself would you:
Definitely Probably Would
Would Would Not
a. Tell my friend to call a hotline. 0 0 0 0
b. Talk to an adult about him/her. 0 0 0 0
c. Talk to my friend without getting anyone else's 0 0 0 0
d. Get advice from another friend. 0 0 0 0
e. Respect his/her privacy & keep it a secret. 0 0 0 0
Which of the above would you be most likely to do? Write the letter of your choice here:
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You're feedback is very important to us.
Please circle the number indicating your answer.
1. Overall, how would you rate your English
classes this marking period?
2. How would you rate the suicide
education classes (Includes
The Turning Hour)?
3. Did you learn anything new in the
suicide education classes?
1 2 3 4
1 2 3 4
1 2 3 4
3a. If you answered 1 or 2, what did you learn?
4. Was the information presented clearly in
the suicide education classes?
5. The suicide education classes were
6. How do you think the suicide education
program will help you deal with your
7. How do you think the suicide education
program will help you deal with your
2 3 4
2 3 4
8. The suicide education program was Helpful Neutral Not
1 2 3 4 5
If you answered 1 or 2, how was it helpful?
It you answered 4 or 5, how was it not helpful?
9. Do you think other high school students in your area should participate
in the same program? Yes No
10. Did you ask any questions or make comments during the suicide awareness program?
11. If no, why not? (You may circle more than one answer)
11 a. Not enough time
11 b. Nothing to ask/say
11 c. Presenter did not ask for questions or comments
11d. Everything was covered
12. Did you miss any of the suicide awareness classes? Yes No
12a. If yes, how many?
ALACHUA COUNTY CRISIS CENTER SUICIDE PREVENTION PRESENTATION
ADOLESCENT SUICIDE PRESENTATION
What is suicide attempt?
What is completion?
Who is a Survivor of Suicide?
Z 2nd leading cause of death for teens ages 15-19.
Z Each year approx. 12 suicide deaths for every 100,000 adolescents-
1 Which means that in an average high school class it is likely that 3 students (2
girls and 1 boy) have either made an attempt or had thoughts of suicide in the
last 12 months.
Z 60% of teens have reported having suicide ideation
Z Adolescent males are 4.8 times more likely than females to complete suicide.
Z Know why?? Firearm vs. pills
Z Females---more attempts (3-4 times)
-> How many of you have been touched by suicide in some way?
-> Who commits suicide? How would you describe them?
Profile of Suicidal Teen: Why do people attempt suicide...
I will tell you about one client I have who is constantly thinking about suicide and through my
description of her you will recognize suicidal teens that you may have come across.
Z Feelings: Hopeless, despair, loss of control, ashamed, unloved
Says in moments of her deepest despair, she feels so much ache and pain as if she is rotting
inside and can do nothing about it.
Feels like she doesn't belong anywhere-no one understands her, she trusts no one to any great
extent, in her worst moments she truly believes no one cares, no one loves her and that no one
would be impacted by her death--- one of the most dynamic teens I have ever met.
Z Thoughts: she thinks-as many suicidal teens do-nothing will ever
change... life is not worth living, she grows tired of putting on what she calls
her armor just to go through another day of surviving-there is no part of her
that feels alive.
In moments of high lethality, she can't see any other options--- tunnel vision.
Z Biggest Myth-that talking about it will cause it to happen
Z People "choose" suicide: "Suicide is not chosen, it happens when pain
exceeds resources for coping with pain"
I Abusing drugs and alcohol
Z Change in sleeping or eating
Z Talk about suicide and/or no reason to live
Z Preoccupied with death and dying
Z Withdraw from friends and social activities
Z Recent severe loss-esp. a relationship
Z Loss of interest in hobbies, work, school
Z School problems/crisis
Z Problems in family/crisis
Z Legal problems
Z Loss of interest in personal appearance
Giving away possessions and other final preparations
Question is not, "how do you stop them from killing themselves?" but rather "How do you help
them find a way to go on?"
What would be helpful??
Z Listen-let them know you care-active listening
Z Don't give advice at first
Z Don't ask a lot of questions, let them tell their story
Z Help them feel understood
Z Acknowledge suicidal feelings---say them aloud-name all taboos
Z Eventually discuss coping skills, resources and strategies to use
What is not helpful?
Z "You should feel lucky"
Z "You are better than most people"
Z You're smart, good kid"
Z "It will all be ok"
Z "It is not so bad"
Z "Why don't you just get busy, you'll feel better"
Lethality Assessment: Balancing these questions with empathic responses to their emotions
-> How will you kill yourself?
-> When do you think you might kill yourself?
-> Where will you kill yourself?
-> Means-Do you have the gun/pills/rope?
-> Who knows-notify parent or guardian
-> Alachua County Crisis Center: 24 hour hotline: 264-6789
-> Suicide Hotline: 24 hour hotline: 1-800-Suicide
-> School Counselors, teachers, other trusted adults
-> Meridian Crisis Stabilization Unit (CSU): Suicide Assessments/inpatient
THE TURNING HOUR
ABOUT THE AUTHOR
THE NOVEL IN BIBLIOTHERAPY
Review of Professional Literature on Bilbliotherapy
Counseling Group Guide
THE NOVEL IN CLASSROOM INSTRUCTION
Comprehension Check and Key
Character Study Activities
READING GROUP GUIDE
Although a dark subject about a heartbreaking national crisis of 1.3 million teen suicide attempts
per year, this novel, in the hands of humorist and NPR Morning Edition commentator, Shelley
Fraser Mickle, lifts the reader into the realm of knowing how to nurture and protect resilience.
The Turning Hour explores teen despair, weaving the viewpoints of Bergin, a high school senior,
with that of her mother, Leslie, to unravel the mystery of why Bergin, in the middle of her senior
year, attempts suicide and then struggles to regain a life she can value.
Peopled with characters that could live in anyone's neighborhood--two husbands struggling to
understand themselves and the women they love, an African-American psychiatrist with a secret
of her own, a stepbrother who looks at the world with "amazed" grace, two senior citizen
geldings who don't know much about horse whispering but understand a little about cussing, and
a pig who lives behind an azalea--this is a mesmerizing novel about beating the blues and
learning how to take care of one's own life. (ReadingGroupGuides.com)
The importance of mature, professional adults discussing suicide with teenagers in a positive
setting cannot be overstated. Author Mickle wants to save lives. The goal is that this Educator's
Guide can provide assistance to teachers, guidance counselors, ministers, and other helping
professionals as they use The Turning Hour in classroom literary study or counseling group
bibliotherapy. Most appropriate for high school students and older, the novel should be viewed in
the context of that genre, in contrast to the plethora of nonfiction on the subject of teen suicide.
This guide is not intended to be a treatise for professionals on the subject of teen suicide; rather,
it should be a starting point to facilitate dialogue between adults and teens. The novel's theme of
resilience provides a positive approach to dealing with tough personal issues.
The educators who developed this guide hope that both professionals and students who use these
ideas experience the gift of personal growth.
Mary Anne Wagner, Language Arts and Guidance
Rita Page Language Arts
Linda S. Myrick Guidance
Marilyn Bishop Shaw Language Arts
Catherine Berg Language Arts
Pat Lucas Technology
Terri Johnson Technology
A REPRINT FROM TEENREADS.COM
Shelley Fraser Mickle was born in 1944, and grew up in Arkansas and Tennessee. The mother of
two grown children and the wife of a pediatric neurosurgeon, she now lives in Florida on a farm
with her three horses, two dogs, one cat, and eight cows. Her first novel, The Queen of October,
was a 1989 New York Times Notable Book; her second novel, Replacing Dad, became a CBS
movie and is now frequently shown on the Hallmark Channel, starring Mary McDonnell and
heartthrob Eric von Detten.
Shelley began reading her humorous essays on National Public Radio in 1995, and her collection
of some of these was published in 2000, titled The Kids Are Gone; The Dog Is Depressed and
Mom's on the Loose. She also writes a weekly newspaper column called "Novel Conversations"
which works like a book club.
March 26, 2002
Teen suicides have reached epidemic numbers in our country, and many parents are at a loss to
know why their teenagers feel so hopeless or even how to recognize the signs of depression.
Shelley Fraser Mickle, author of The Turning Hour, answers some questions for
Teenreads.com's Kathy Hale on what she discovered in researching her novel and what she
hopes her new book will accomplish.
TRC: What inspired you to write a book about teen suicide?
SFM: In 1995, I was over at the beach near St. Augustine, which is near where I live, and I met a
woman who said she had read my two novels and felt that she had known me forever.
Furthermore, she said she felt that perhaps I could know her in ways no one else could. And she
wanted to give me a story she had lived, and encouraged me to do with it as I might. She then
proceeded to tell me over the next hour and a half how her child, as a senior in high school,
attempted suicide and that something she had unwittingly done had contributed to her child's
drastic decision. She then explained that even though it was the darkest time in her family's life,
it turned out to be one of the most enriching. For they all emerged in an enlightened kinship. She
ended by saying she knew she would never talk about this again, for suicide is such a taboo
subject, and yet, so much was learned from this dark time.
Well, I filed this story away. I simply did not want to "go there." I have to admit, though, it was
one helluva plot; but still, I didn't want to have to crawl into the dark hole into which that young
adult had fallen--which is what I knew I would have to do in order to write a literary novel. Then
one day years later, it occurred to me: If I wrote this story from the point of asking, once
someone has made the drastic decision to give up life, then is turned back physically, how does
one get back emotionally? In other words, how does one come back to an emotionally vibrant
I called around town to find an expert on teen suicide. It turned out the person I was referred to
was someone who was getting her Ph.D. while we were raising boys together--carpooling, etc.
When I told her what I was thinking about doing--writing a novel about young adult suicide--she
said, "My God, Shelley, you've got to do it. You won't believe how many young women and men
(of high school and college age) I see in my practice each month who have attempted to end their
The new statistics from the CDC is that one in five high school students each year considers
committing suicide, and 1.3 million attempt to end their lives. This is a heartbreaking crisis. So
off I went--writing The Turning Hour--because I could not say no to bringing this most pressing
story to life.
TRC: Are Bergin and her family based on real people?
SFM: No. As a novelist, all my characters are composites of people I have known. I always have
to find myself within them, too. For I can't bring a character to life unless I've had dinner with
them, showered with them, taken a long trip and paid our income taxes together! I borrow stories
from my friends and family, too, as my Acknowledgments admit. I chose to write the book from
a young woman's viewpoint rather than a young man's, because I had just finished writing
Replacing Dad, my novel told by a 15-year-old boy and his mother, and I wanted a different
challenge. The point is, though, the cultural influences that lead to Bergin's crisis in The Turning
Hour are also many of the same pressures for young men.
TRC: Has suicide ever touched your life?
SFM: No, thank goodness. Looking back, however, I realize that a young man I once dated in
my twenties committed suicide. If I live a story, I can't write about it. I'm too close, and too
emotional. I need that distance. But of course, all literary artists have to understand the emotions
of their characters and find them within themselves. That's the way we work.
TRC: In researching your story, did you draw any conclusions about the most prevalent cause of
SFM: Suicide is always a complicated set of events leading to a profound sense of hopelessness.
Basically, though, loss is always a part of the set of circumstances that leads to suicide--loss of a
relationship or loss of self-worth through humiliation. And then that loss is coupled with
isolation. Our literature and media have romanticized too often the act of suicide following the
loss of a loved one. Clusters of suicides can result. The depression that leads to suicide creates a
distorted sense of reality. That's why the facts leading to a suicide never seem believable. Of
course we want to deny that any reason is a good one to end a life. But simply, the person who
wants to end their life sees the world in their own very logical but twisted way. It all makes
perfect sense to them. And frequently it provides a secret form of having power over what is
uncontrollable. Chemical imbalances seem to always be in play. I recently attended Grand
Rounds on Teen Suicide at the University of Florida Medical School, and the chemical
imbalances from depression were emphasized. Also disturbing was the statistic that 40% of
young adults hospitalized for a suicide attempt drop out of treatment. This is why I think a novel
such as The Turning Hour may be able to reach young adults in ways that conventional treatment
cannot--and aid in prevention.
TRC: Why do you think that so many parents miss the signs of their kids' depression?
SFM: Kids are good at hiding their most intimate feelings from their parents because they are at
that time in life when they are pulling away from their family and asserting their independence.
Frequently in their flight toward independence, communication lines break down. It's a difficult
and painful time for both parents and kids because it's nature's way of turning kids into adults--to
prepare them to go out into the world on their own. Often, parents forget to listen to their young
adults. They forget how to be silent and just spend time doing anything at all with their kids who
are in the midst of the struggle to become adults. It's always important for parents to lend their
kids their strength and not use it against them. Part of being a good parent is empowering the
TRC: You capture the depressed personality very well in The Turning Hour. Have you ever had
any personal experience with depression?
SFM: No one gets out of living their life without knowing something about The Blues. I have
not had a personal experience with clinical depression, other than dealing with family members
who have suffered from it. A number of years ago, I read an interesting article on depression that
indicated some experts believe depression has a chemical basis that at one time aided our
primitive ancestors to hibernate when food sources were low. This seems very possible to me--
that there could be biological reasons for our moods that they help us survive. Certainly, The
Blues have always made me emerge feeling stronger, more clearly focused, and energetic. I like
looking at Depression in this positive way.
However, I am talking here about ordinary run-of-the-mill Blues, and not clinical depression,
which is a complicated medical condition. From what I understand about the chemical basis of
clinical depression, it requires diligent and professional treatment that sometimes must be
attended to for a life-time. I have always felt, though, that it is these challenges in life which
make us who we are. For someone to be diagnosed with clinical depression, seek treatment,
continue to monitor and live with their condition, they become heroes in the story of their own
lives. These people are smart!
I know that the fact that I had polio in 1950, spent most of my childhood in children's hospitals,
then in wheelchairs, braces, and crutches has made me on special terms with myself I would not
be who I am without having experienced this and knowing how to take care of myself. I strongly
believe that these experiences are like buying strength on the lay-away-plan. We get to pull out
the goods, one day. How we wear them is our personal decision.
TRC: According to your website, you have a dog named Stella, and so does Bergin. Is that just a
SFM: I thought it would be fun to put my dog Stella in the novel. The name of my farm is also
Blueberry Hill Farm. I had no ulterior motive other than to be playful. A good friend of mine had
a pot belly pig named Spam, too; and I thought that was such a cool name for a pig, he ought to
be in the book also.
TRC: Do you think that Leslie's childhood experiences influence how she reacts to the situation
SFM: Most definitely. Children of alcoholics are always quick to deny problems and good at
covering them up. Shame is such a strong force in their lives that subconsciously they do all sorts
of things to make themselves feel better about the secret they are keeping--that someone in their
family is not functioning and cannot be related to in a healthy way.
TRC: When Bergin is hospitalized, Leslie tells her colleagues that she has mono or hepatitis. Do
you think that most parents are honest about their children's mental illnesses, or do they choose
to hide them?
SFM: You know, parenting can get as competitive as the last lap in a NASCAR race. Being a
parent, I can say this with no qualms. I've been there and done that myself, and have also been
greatly disturbed by the pressures some parents can put on their kids. Luckily, the powers in the
universe tend to even things out for parents--give them one easy-to-raise kid who seems to do
everything to society's highest standards. Then they are given one child who makes them know
the real values in life--that being a good, kind person who can be steady, loving, and have a
humorous outlook on life is worth more than any number of degrees from prestigious colleges or
a fat bank account. Furthermore, these are talents no one can buy. So yes, parents tend to hide
their children's problems. Then often they wise up and see the value in how difficulties help kids
grow, and then they themselves begin growing. It's the parents who don't let their kids teach
them things who miss out. These are the ones I feel sorry for.
TRC: What is the one thing you would like teens to learn from reading The Turning Hour?
SFM: Resilience. If there is one thing I want readers of all ages to take away from The Turning
Hour it is that life requires patience. Bad weather passes. Don't let our culture dictate to you who
or how you should be. Follow your head and hold hands with your heart. Growing up is a
tempestuous time. It's supposed to be. You've got to try out all sorts of things and make mistakes.
Unlike Bergin, in the beginning of the book, don't ever think anything is hard and fast.
Everything changes. The way you feel now won't be the way you feel always.
I would also like men to read The Turning Hour so they would see more clearly that their
children don't want them to be only providers. Fathers play a crucial role in the emotional life of
their children. I don't want The Turning Hour to be seen as only a "Babe Book." And remember,
my novel is about Life, not Death. To go through this world, we all have to learn how to take
care of our lives.
TRC: What advice would you like to share with parents about dealing with their teenagers?
SFM: Listen. Wait. Be patient. And enjoy them. Lend them your strength, rather than overpower
them. And don't try to be a teenager again with them--parents acting like teens make for too
many in the house!
TRC: What are you working on now?
SFM: I've got three things going and have to decide which to finish first. One appears to be a
nonfiction humor book called Old Wives Tales Told by a Half-Dozen Old Wives. I also have a
new novel going, and a memoir. I've lived long enough to almost become interesting--even to
REVIEW OF PROFESSIONAL LITERATURE ON BIBLIOTHERAPY
Lenkowsky, R. (1987). Bibliotherapy: A review and analysis of the literature. The Journal of
Special Education, 21(2), 123-32.
Bibliotherapy is a specific, progressive, planned therapy that includes:
Identification with the characters-- Situations, or elements of a story, enable the reader to
see his or her problem from a different perspective and thus gain hope and catharsis.
Catharsis-- a tension release that allows the reader to be open to insight and change.
Insight into one's own motivations and actions allows for a positive change in attitude
Pardeck, J. (1990) Using bibliotherapy in clinical practice with children. Psychological Reports,
Bibliotherapy should not be viewed as a single approach to treatment but rather as an
adjunct to other therapies.
Gladding, S. & Gladding, C. (1991). The ABCs of bibliotherapy for school counselors. The
School Counselor, 39, 7-12.
Two types of bibliotherapy are described:
1. "Reactive" bibliotherapy, which is based on the premise that clients' identification with
literary characters similar to themselves is helpful in releasing emotions, gaining new directions
in life, and promoting new ways of interacting with others through catharsis, insight or emulating
2. "Interactive" bibliotherapy, in which the processes of growth, change and healing are
facilitated by guided discussions of feelings and cognitive responses to the material.
With appropriate guidance from a facilitator, bibliotherapy can benefit students:
Affectively, by providing an avenue for the release of pent up emotions that may have
previously interfered with personal growth and constructive interpersonal relationships.
Behaviorally, by providing characters that may model actions for the reader, including
appropriate ways of relating to self and others.
Cognitively, by providing opportunities to learn selective strategies for approaching
potential problems and thereby preventing or reducing unwanted stress.
Some important issues to watch for include:
Participants projecting their own motives onto the characters, thus reinforcing their own
perceptions and solutions.
Participants discounting the actions of characters and thus failing to identify with them or
even using them as scapegoats.
Participant's failure to recognize oneself in a character, defensiveness, or denial.
Facilitator's failure to appropriately pace exploration of issues evoked by the story to the
participant's level or readiness.
Aiex, N. (1993). Bibliotherapy. Bloomington, IN: ERIC Clearinghouse on Reading and
Bibliotherapeutic intervention may be undertaken for many reasons:
to develop self-concept
to increase understanding of human behavior or motivations
to foster ones self-appraisal
to encourage finding interests outside of self
to relieve emotional or mental pressure
to show that one is not the first or only person to encounter such a problem
to show that there is more than one solution to a problem
to help a person discuss a problem more freely
to help a person plan a constructive course of action to solve a problem
Motivate the individuals) with introductory activities.
Provide time for reading the material.
Allow incubation time.
Provide follow-up discussion time, using questions and leads that move participants)
from literal recall of facts and story through interpretation, application, analysis,
synthesis, and evaluation.
Provide for evaluation of progress by practitioner and by participants) and move
participants) toward closure.
Sridhar, D. & Vaughn, S. (2000). Bibliotherapy for all. TEACHING Exceptional Children, 33,
Bibliotherapy is an intervention for dealing with stressful situations or to enhance self-
understanding, using books with a therapeutic content.
The reader should experience:
Identification the student should be able to identify with the age and behaviors
of the main character and with the events of the story.
Catharsis the student then relates to the situation and feels emotional ties with
the main character. Through emotional involvement with the main character and the
story, the student can experience some relief from emotional stress.
Insight by analyzing and developing opinions about the main character and
events of the story, a student can develop a deeper understanding of his/her own situation.
By exploring alternative behaviors for the main character, the student can develop
Counseling Group Guide
Although The Turning Hour can be used effectively in individual counseling, this Guide focuses
on group counseling, based on the model outlined in Sridhar and Vaughn's Bibliotherapy for All
(Teaching Exceptional Children, 33,74-82).
Most important is good communication among professionals using The Turning Hour. Guidance
counselors should discuss the approach with significant administrators, classroom teachers, and
even parents, since the counseling group is focused on sensitive topics such as teen suicide and
divorce. Perhaps the best approach is a co-teaching model where the classroom teacher and the
counselor work together.
Sridhar and Vaughn outline a four-step process, which provides a flexible framework for
counselors and teachers.
Step 1 Getting Ready
* Make sure the book is suitable based on the following criteria:
* The main character and storyline are relevant to the student.
* The book is at an appropriate level, developmentally as well as reading.
Step 2 Before Reading
Give students an introduction to the theme of the book, the major events in it, and the
Encourage students to compare their experiences with situations in the book.
Help students make predictions about the content of the book based on the information
given and their own knowledge about people similar to the main characters.
Step 3 During Reading
Ask questions that help students summarize the text and facilitate their identification with
the main character.
Ask questions about what they might do as the main character, perhaps encouraging them
to collaborate in a process of problem solving.
For additional ideas, refer to Essay/Discussion Questions, page 21, and Reading Group
Guide, pages 45-46.
Step 4 After Reading
Facilitate deeper discussion, perhaps in smaller groups, about the story and how the
characters felt and what the students themselves might do in situations from the book.
Use follow-up activities that allow students to express themselves more fully.
A summary of the book from the point of view of someone in the book other than the
A diary for a character in the story
A letter from one character to another or from the student to a character
A different ending for the story
A "Dear Abby" letter that a character may have written about a situation in the story.
Create a drawing or collage representing the story, the growth of the main character or a
Role-play and discussion:
Role-play events in the story.
Discuss how the outcome of the story could be changed and how alternative behaviors of
the characters could cause changes in the story.
For additional ideas, refer to Essay/Discussion Question, page 21, and Reading Group
Guide, pages 45-46.
The chapter synopses provide a brief explanation of key chapter event. A teacher can use these
synopses as tools for reviewing events or locating scenes in the novel.
Part I of the novel deals principally with the past and builds to an epiphany for both Bergin and
Leslie that answers the question of why Bergin attempted suicide. Part II deals with the present
and future and leads both Bergin and Leslie to epiphanies that answer the question of how they
can go on with their lives.
Chapter 1 ~ Bergin
The chapter tells how Bergin had swallowed a bottle of aspirin the first week in December at her
father's house. The chapter also includes some school background information such as how
Bergin was the captain of the cheerleaders but "defected" to the soccer team.
Chapter 2 ~ Leslie
Leslie tells about what she was doing the day the Bergin committed suicide. She was in court
defending a client, Richard Murphy ("Hoot"). She also describes her own parents and growing