Incorporating the Developmental Considerations in a Proposed Forgiveness Education Intervention for Suicidal Adolescents

Abstract

This paper first explores the risk factors associated with adolescents’ suicidal thoughts, attempts, and behaviors within different developmental domains and in the environment, using the developmental systems theory (DST). The most frequently identified risk factor for suicide, psychological pain, is examined in terms of its nature, expression, and possible cause. This paper criticizes the current empirical research of suicidal adolescents’ interventions on two issues: (1) lack of concern for fundamental issues in lifespan development and (2) inadequate treatment of the emotional needs resulting from the psychological pain in adolescents. Finally, this paper proposes forgiveness education intervention as targeting the emotional needs, particularly psychological pain, for suicidal adolescents.

1. Introduction

Suicide is the second-leading cause of death for adolescents aged 10 to 14 years and the third-leading cause of death for adolescents aged 12 to 19 years, according to Centers for Disease Control and Prevention [1], with many more youth reporting thoughts of suicide as well as suicide attempts. Suicidal behavior is developmentally mediated by chronological age: no cases among children ages four and younger; a low rate for children ages 5 to 9; increasingly high rates in early to mid-adolescence (10- to 14-year-olds) and mid-to-late adolescence (15- to 19-year-olds); climbing up to reach its peak around age 50 before declining through most of later adulthood. In the last two decades, there has been a dramatic rise in suicide rates in the US, especially among the adolescent population, especially African American youth [2] and LGBTQ youth [3]. In addition, adolescents have shown increased rates of suicide attempts from early- to mid-adolescent in both clinical and community-based samples [4,5,6], which is one of the primary reasons for child psychiatric emergency room visits and hospitalizations [7] and the best predictor of future attempts and deaths by suicide [8].

2. Risk Factors in Different Developmental Domains of Suicidal Adolescents

Adolescents are developmentally different from adults in the risk factors contributing to their suicidal behaviors. Biologically, early adolescents encounter significant physical changes associated with puberty. Cognitively, adolescents may focus more on proximal consequences of behavior than more distant goals when making decisions [9]. Emotionally, adolescents are more prone to depression, anxiety, and other forms of emotional distress, partially due to their developing brains coupled with hormonal changes [10]. In addition, numerous contextual factors such as family conflicts, academic and disciplinary difficulties, transition to middle/high schools, early traumatic experiences, and disrupted peer relationships could contribute to the increment in risks for adolescents’ suicidal behaviors.

Because suicide is a multifaceted event with biological, psychological, sociological, and cultural elements present at various degrees for different individuals [11], it is helpful to adopt developmental systems theory (DST) to study suicidal adolescents as it acknowledges that development is a dynamic process in the individual who is a whole coordinated, complex system composed of biological, cognitive, and social-emotional domains, and is a part of a family, a classroom, a peer group, a community, and a society. The outcomes of development (i.e., suicidal thoughts, attempts, and behaviors) could be explained at the subsystems level, and development is influenced by the context in which it unfolds [12].

Neuro-imaging studies of brain development reveal that the prefrontal cortex in adolescent brains, which plays a role in decision-making and emotional control, matures slower than other parts, such as the hippocampus and amygdala. This results in a period involving a greater risk of impulsiveness [13]. In addition, the production of glucocorticoids in the hypothalamic–pituitary axis, which is affected by sexual hormones, has been found to fight external challenges and to developing depressive symptoms [14]. The potential suicidal risks of adolescent impulsive behaviors and depressive symptoms arising from the neurobiological factors cannot be ignored when considering individuals’ cognitive and emotional characteristics.

3. Psychological Pain in Suicidal Adolescents

A further investigation of the adolescents’ inner world of thoughts and feelings will continuously help to explore the reasonings and risk factors associated with teen suicide. A study with 521 six-graders over the course of 18 months in the US found that about 1 in 20 had thoughts of killing themselves at one or more of the four assessments, with the most frequently adopted reasonings being “nothing good for me in the future,” “life not worth living,” and “family would be better off without me” [15]. The qualitative analysis found that adolescents who have contemplated suicide had stressful situations with family members. This suggests the developmental characteristics of adolescents who are in a vulnerable period, which can easily be distressed by conflicts in close family relationships. Another longitudinal study of Swiss youth showed that although in late adolescence only persistent suicidal ideation was predictive of psychopathology and poor psychosocial functioning in young adulthood, even the transient suicidal ideation in early adolescence was associated with poor young adult psychosocial functioning [16]. This suggests that the emergence of suicidal thoughts at a young age might serve as a greater risk factor for later suicidal attempts or behaviors. This finding can be explained by DST, which states that development at an earlier stage can exert an effect at a later developmental stage, and should be an important sign for parents or caregivers, teachers, and mental health professionals who are in contact with young adolescents.

The links between various emotional traits and adolescent suicidality have been shown in empirical research: depression, anxiety, hopelessness, and high levels of internalized and externalized anger are consistently associated with adolescent suicidal ideation and behaviors. Depression and suicide are intricately intertwined among adolescents: those who experienced depression are 12 times more likely to attempt suicide than those who did not, and more than half who complete suicide had major depression [17]. Anxiety, although not clear as a standalone factor for causing suicide-related behaviors, is evidently a high-risk factor associated with adolescent suicidal outcomes when co-existing with depressive symptoms [18]. Hopelessness is significantly associated with suicidal ideation, suicide attempts, and suicidal intent, even after controlling for depressed mood, according to a study with a clinical sample of 175 children and young adolescents (ages 6 to 13 years) in the US [19]. A similar finding of a significant association between hopelessness and suicidal ideation in a sample of 5557 Chinese secondary students (ages 11 to 18) in Hong Kong also has been reported [20]. Anger was found to be more severely observed in adolescents with a history of multiple suicide attempts in comparison to single suicide attempters, after controlling for a mood disorder diagnosis in 121 US adolescents who were aged 12 through 18 years [21]. A qualitative study [22] with 50 adolescents and young adults (ages 15 to 24), who attempted suicide within three years but were free from suicidal thoughts and feelings for more than six months, allows a more in-depth investigation of the adolescents’ perception of how negative emotional experiences contributed to their suicidal behaviors. Three major themes were categorized as (a) overwhelming despair, described as one of misery, hopelessness, gloom, and emotional pain; (b) shame and self-loathing, described as keeping the feelings and problems a secret to avoid stigma and embarrassment; and (c) alienation and personal isolation, described as feelings as different from people around, unfitting the social structure, and not being understood as a person by anyone. Leenaars et al. [23] pointed out that unbearable psychological pain might be a result of loss of self-identification during the unique identity (ego) development of teens. Suicide is considered a means to escape from unbearable pain.

Psychological pain has been the most frequently identified risk factor for suicide [24]. Yet, there is a lack of systematic study of its prevalence [25]. This is partly because, even though many suicidal attempters or victims reported they had experienced a form of deep, extreme, intolerable psychological pain, the depth of the experience and the meaning of this concept can be hardly captured and described in an all-encompassing way. Shneidman [11] used the word “psychache” to refer to the hurt, anguish, soreness, aching, and psychological pain in the mind. When the pain in the mind is deemed by the person to be unbearable, suicide can occur. Psychological pain is usually referred to as the excessive feeling (or accumulation) of a variety of very intense negative emotions, such as guilt, shame, loneliness, humiliation, sorrow, fear, dread, and angst. In addition, there are several major themes associated with psychological pain—loss, separateness, and emptiness—often described by theoreticians and investigators from different perspectives. For example, loss can be interpreted as the actual trauma of losing (or separating from) a beloved person [26], loss of part of the self [27], or loss of meaning in life, which results in emptiness [28]. Meerwijk and Weiss conducted a concept analysis of psychological pain, identified its common characteristics across five theoretical models, and defined psychological pain as a lasting, unsustainable, and unpleasant feeling resulting from negative appraisal of an inability or deficiency of the self [29].

According to Meerwijk and Weiss’s definition, psychological pain is more of a mental condition than a developmental phenomenon [29]. However, how it is manifested depends on the developmental features of one’s life. In adolescents, psychological pain is often expressed as anger. Zimmerman and Asnis pointed out that very angry and hostile adolescents sometimes may be more at risk for suicide than adolescents exhibiting more traditional signs of depression [30]. Based on an examination of suicide completers’ impulsive-aggressive behaviors across different ages (11 to 87 years), it was found that higher levels of impulsive-aggressive traits were observed among adolescents who completed suicide [31]. A recent study has further confirmed that anger had a significant positive relationship with suicidal ideation, while psychological pain (phrased as “emotional distress” in the article) mediates that relationship among a clinical sample of late adolescents [32]. Uğur and Polat found that anger rumination and psychological pain were significantly associated within a clinical adult sample with a diagnosis of major depressive disorder who have suicidal ideation [33]. Thus, the increase in suicidal behavior in individuals with high psychological pain may be related to the feeling of anger as well as the ruminative thoughts that accompany it. It is not very clear whether anger or psychological pain have a major role in contributing to teen suicidal ideation. Yet it is certain that the interplay of anger and psychological pain has a cascading effect on suicidal ideation in adolescents, especially among those who have already been diagnosed with an emotional issue.

As a mental condition, psychological pain can be triggered by life events that are related to rejection, loss, or separation. Once it is triggered by the negative appraisal of an inability or deficiency of the self, it becomes a lasting, unsustainable, and unpleasant feeling that continuously exacerbates the pathway from the negative life event to suicidal ideation and suicide attempt. A longitudinal study with 2259 high school students (mean age = 15.11 yrs) in Hong Kong confirmed the mediating role of psychological pain in the temporal relationship between emotional abuse and suicidal ideation [34] Other studies have shown that psychological pain is a mediator in the relationship between childhood abuse/trauma and suicide attempts [35,36].

Psychological pain has been studied through suicide notes to explore some psychological dimensions in adolescent suicide as well as to identify the differences and similarities of suicide across the lifespan. Leenaars et al. found that teen suicide notes score higher on Rejection-Aggression and Identification-Egression [23]. Rejection-Aggression is self-directed aggression that comes hand-in-hand with pain because of loss or rejection. Identification-Egression means that the suicidal person experiences deep pain and wants to escape because of the unmet emotional attachment. Both Rejection-Aggression and Identification-Egression show the suicidal individual wants to flee from pain. It is clear that psychological pain exists in suicidal teens’ minds, although not as the central description of suicide notes. It is so intense that individuals become more aggressive toward the self and want to flee from pain. Another study focused on the suicide notes of young adolescents (15 years or younger) identified that psychological pain was a major described theme among this age group [37].

4. Risk Factors in Different Developmental Contexts of Suicidal Adolescents

As DST notes, it is impossible to study adolescent suicidality without situating it in the multiple contexts of developing individuals, as well as the external factors present in the environment. Multiple risk factors in the family context include physical or sexual abuse, parental conflict, poor family or parent–child communication, loss of a caregiver due to separation or death, and psychopathology in first-degree relatives [38,39]. A family environment that lacks communication of feelings and personal issues and a parent–child relationship that lacks closeness, intimacy, and trust can contribute to the inability to emotionally regulate in suicidal adolescents [22]. Several large-scale empirical studies have found that even after controlling for depression and other emotional disorders, family variables, such as family support, communication, and parental monitoring, are still significantly associated with suicide attempts/ideation [40,41].

As the peer relationship gradually becomes a key component in developing adolescents, negative experiences with peers, such as bullying, victimization, and isolation, are risk factors associated with adolescents’ suicidality. Bearman and Moody found that social isolation from peers and intransitive friendships significantly increased the odds of suicidal ideation for girls [42]. Klomek et al. identified a clear relationship between both bullying victimization and suicidal ideation and behavior in children and adolescents [43]. Suicidal ideation and behavior were greater in those who were bullied, when controlling for age, gender, race/ethnicity, and depressive symptoms [44]. Pathologic Internet use as well as cyberbullying were also found to be significantly correlated with suicidal ideation [45,46]. Sexual and gender minority (SGM) youth report greater odds (approximately 2 to 7 times higher) of attempting suicide than their heterosexual peers [47]. SGM youth reported a much higher rate (75%) of experiencing bullying than all youth (20%) [48]. In addition, SGM youth more frequently report feeling less supported by their school or communities than heterosexual youth. Studies found that it was the time at which SGM youth who contemplated or attempted suicide felt unsupported when they were the most depressed [49].

5. Targeting Psychological Pain with Forgiveness Education Intervention

A comprehensive analysis of the risk factors associated with suicidal adolescents’ urges for interventions, with the focus on the emotional needs stemming from the psychological pain. The forgiveness education intervention (FEI) targets the emotional needs connected with psychological pain in adolescents. The content, modality, and effectiveness of FEI are investigated based on current research and clinical evidence.

Forgiveness is a virtue that begins with a conscious decision to abandon one’s right to resentment, judgement, and indifferent behavior toward the offender and involves fostering the undeserved qualities of compassion, generosity, and even love toward the offender [50].

The development of forgiveness is thoroughly depicted in Enright’s Process Model of Forgiveness, which is the most widely used and scientifically supported model for forgiveness interventions [51]. The meta-analysis by Akhtar and Barlow shows this model to be the strongest of the different intervention approaches [52]. Going through the process of forgiving, individuals will be able to gain insights into the injustice, express their own emotions associated with the injustice, choose to forgive by acknowledging the inherent worth of the self and the offender, and undergo change in affect about the person, the self, and the relationship.

The development of forgiveness could help relieve suicidal adolescents from psychological pain. FEI is based on the four phases in the Process Model of Forgiveness. In the Uncovering Phase of forgiveness, identifying the injustice and acknowledging the feelings associated with the injustice are both significant steps in dealing with the psychological pain. In most cases, negative appraisal that causes psychological pain originates in injustice. In young children’s lives, the most injustices experienced are within the context of family, especially within the parental relationship. Clinicians often discover that the origins of the greatest anger in children come after the greatest degree of disappointment in the parental relationship, especially that with the paternal figure [51] (p. 175). Adolescents may identify recent injustices in peer or romantic relationships. However, as Enright and Fitzgibbons [51] (p. 205) noted, the origin of unconscious anger is usually from hurt associated with parents, and it is often helpful to resolve anger with a parent who had disappointed or hurt them before working on the most recent injustice and the anger associated with it. It is vital to help adolescents who have suicidal thoughts to identify the cause of their anger and to express the anger, which they are most likely to deny when experiencing a fearful relationship. However, expressing anger alone does not mean that individuals can be free from the burden of resentment. Instead, it often might lead to a desire for revenge unless the resentful feeling is uncovered and resolved. Without proper uncovering and resolution, anger can be displaced onto self and others in other close relationships even after many years, resulting in psychological pain. In addition to identifying the cause of their anger, it is also important to encourage adolescents who have contemplated suicide to express all their feelings, which may have been repressed for a long time. After proper expression of the repressed emotions, this opens up the possibility for individuals to consciously consider the option of forgiving the offender, as one way to resolve the anger.

In the Decision Phase, the goal is to explore alternatives other than questing for revenge. A question for the suicidal adolescents to ask is: if the old strategies kept me feeling angry and distressed, what other options do I have? At this stage, the focus is to understand the operational definition of forgiveness, as well as how to distinguish what forgiveness is from what forgiveness is not. Because the psychological pain in suicidal adolescents often leads to self-blame as incapable or worthless, the potential danger of misinterpreting forgiveness may worsen the situation. The following depicts what forgiveness is not: (a) forgiveness is not tolerating or enabling angry, abusive people to express their anger; (b) forgiving does not mean being a doormat or acting in a weak manner; (c) forgiveness does not limit healthy assertiveness; it does not mean trusting or reconciling with those who are abusive, insensitive, or show no motivation to change their unacceptable behavior; (d) forgiveness is not necessarily going to others and informing them that one is forgiving them [51] (p. 174). It is important to have open-minded dialogues with suicidal adolescents instead of forcing them to accept the ideas. As individuals learn more about forgiveness, they are more willing to choose not to harm the offender, self, and other people, rather than spill the anger on them. In this phase, it is normal that a mixture of feelings such as anger, sadness, happiness, and confusion still exists.

In the Work Phase, the goal is to help suicidal adolescents understand the deep worth of themselves and then gradually shift the focus from themselves to the other person, with the goal of a deeper understanding of the offenders. It is critical to introduce the important concept of inherent worth to suicidal adolescents; they should begin to see their own worth first by understanding their worth is not diminished by others’ injustice or criticism. It helps to relieve psychological pain so the individual will have less aggressiveness towards the self. Then, although it is not easy, it is a vital process for them to recognize that inherent worth also exists in the one(s) who offended them. The empathetic feeling begins to develop gradually at this stage (see

Table 1. Cognition, emotion, and behavior in the four phases of forgiving.

Phase of Forgiving	Cognition (Thinking)	Emotion (Feelings)	Behavior (Actions)
Uncovering Phase	Identify the injustice
	Acknowledge the feelings	Anger, sadness, etc.
Decision Phase	Learn what forgiveness is vs. is not		Refrained behaviors: not to harm the offender, self, or others.
	Consider forgiveness as an alternative	Mixture of feelings of anger, sadness, confusion, happiness…
Work Phase	Switch the focus from myself to the other person Try to understand the person deeper	Empathy (feeling the same feelings as another person)	Refrained behaviors: not to harm the offender, self, or others.
	See the other person’s pain	Sympathy (we feel sorry for a person)
	Willing to suffer with the person	Compassion (feeling to suffer with the one who caused the hurt)
	Further acknowledge the inherent worth Willing to give up the thoughts of resentment	Agape love (loving feeling toward someone who may seem unlovable and undeserving of the love)
Deepening Phase	Find meaning for self and others in the suffering Realize one is not alone in the pain	Agape love (loving feeling toward someone who may seem unlovable and undeserving of the love)	Expressive behaviors: kind, respectful, generous thoughts, words, and actions towards the offender, or even reach out to help

). Thus, it is important to emphasize the inherent worth of the self, as well as the balance of expressing forgiveness—extending the gifts of kindness, respect, and generosity to both the self and the person who offended. In some situations, it might be more important to work on understanding the inherent worth within the self as well as self-forgiving with suicidal adolescents. This is an important stage as it intentionally cultivates agape love, a loving feeling toward someone who may seem unlovable and undeserving of the love. By understanding the other person deeper, individuals are able to see the pain that also resides in the other, not only in themselves. Adolescents with suicidal thoughts often think that their pain is unresolvable. At this stage, as individuals acknowledge other people’s pain, the perception of their own pain might change, and so might the feeling of pain be perceived as less intolerable than before. As a result, more refrained behaviors can be observed as they continue to choose not harming themselves and others, including the offender.

In the Deepening Phase, as individuals find increased meaning in suffering, they feel more connected with the self and others and experience decreased negative affect. They realize that one is not alone in the pain and suffering. As a result, they might be more willing to help others who are suffering by expressing kind, respectful, and generous thoughts and behaviors.

What distinguishes FEI from skill-based behavioral therapies is that it does not aim to teach any behavioral skill or expect any behavioral change until the very late stage of the Deepening Phase. The Uncovering Phase allows individuals extended time to express their anger and other repressed emotions. As most children and adolescents have been socialized to hide their anger and other “undesired” emotions instead of acknowledging them as normal and natural feelings [53], being able to express anger, sadness, and distress toward injustice is powerful and healing. The Decision Phase helps individuals to grasp the understanding of the true meaning of forgiveness and inherent worth in both the self and the offender. Because of this special focus on treating excessive anger through forgiveness, clinical evidence has shown that the resolution of this resentment helps cope with many psychological disorders in a more effective way, including attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and panic disorder [51].

To date, besides the documented clinical evidence for the effectiveness of forgiveness therapy on adolescents (mostly using individual therapy), no empirical study has been conducted that directly targets suicidal adolescents with forgiveness intervention. However, there is cross-sectional evidence showing that individuals with past suicide attempts were significantly less forgiving toward themselves and others [54]. A systematic review investigating the relationship between forgiveness and bullying (or cyberbullying) in adolescence provides evidence that adolescents with higher forgiveness levels bully less, and adolescents with higher forgiveness show less victimization [55]. More specifically, it is found that among adolescents who were victims of bullying, individuals with a higher level of forgiveness were less vulnerable to experiencing suicidal ideation [56].

Besides applying individual forgiveness therapy, more and more empirical studies have focused on group intervention of teaching forgiveness education curricula in schools. A recent meta-analytical study shows a significant anger reduction after FEI [57], which supports the view that the group intervention of forgiveness education could be potentially applied to adolescent suicidal intervention. The other noteworthy finding of the meta-analytical study on forgiveness education intervention is that comprehensive and lengthy school-based universal prevention efforts are often ineffective with middle adolescents [58]. Rapp et al. identified that forgiveness education interventions are most effective within early to middle adolescents (g = 0.58, grades 6 to 8) among all academic divisions (grades 1 to 3, grades 4 to 5, grades 6 to 8, grades 9 to 12) and continue to show effectiveness from middle to late adolescents (g = 0.44, grades 9 to 12) in reducing anger and increasing forgiveness [57]. The moderator analysis of this study shows that the most effective curricula used in the forgiveness education interventions are based on the Enright Process Model of Forgiveness. As an example, a literature-based curriculum begins by introducing the concepts of forgiveness, inherent worth, and other related constructs of kindness, respect, and generosity, and then teaches recognizing emotions associated with injustice before going through the process of forgiving with an identified injustice. Each grade level has its own curriculum with age-appropriate stories. The stories, with forgiveness resolutions, then can be applied to students’ personal conflicts as they emerge in the school setting.

An advantage of the school-based prevention approach is that it could reach large numbers of adolescents. However, a universal prevention program might overlook the unique needs of the individuals. To implement FEI in schools as well as to cater to individuals’ needs, the program could begin with a screening process and use the three-tier model in a Positive Behavioral Interventions and Supports (PBIS) program. As Skaar et al. point out, the severity of offense must be considered prior to a forgiveness education intervention among the adolescent population [59]. To identify individuals’ needs and struggles, the screening process takes place before the intervention. The screening could include a measure to evaluate the severity of current wishes and plans to complete suicide, such as the Beck Scale for Suicide Ideation (BSI) [60]; a measure to evaluate psychological pain, such as the Mee–Bunney psychological pain rating scale (MBPPAS) [61]; a measure to evaluate the degree of forgiveness, such as the short version of the Enright Forgiveness Inventory (EFI-30) [62]; or the Beck Anger Inventory for Youth and the Beck Depression Inventory for Youth in the Beck Youth Inventories Second Edition (BYI-2) [63]. These could be used to identify individuals who are high in anger and/or depression, and who may be at risk for suicidal thoughts and behavior.

After screening, the three-tier model in the PBIS program is adopted for further implementation of FEI in schools. Tier 1 introduces FEI to everybody in a classroom. The goal is to help students learn about forgiveness. It is recommended that schools employ forgiveness education as part of the school’s comprehensive social emotional core curriculum [59]. It can be part of the regular guidance curriculum at the elementary level and infused into the core through health courses or advisory curricula at the secondary level. The forgiveness curriculum guides for pre-kindergarten through grade 12 can be used as guides for the forgiveness education occurring at Tier 1 [64].

Tier 2 targets students who have more severe suicidal ideation and have made an attempt, potentially have more psychological pain, and are high in anger and depression. The goal is to help students walk through the process of forgiveness to address their past hurtful experiences. When FEI is implemented in small groups, the grouping should be under careful consideration, for example, by shared group identity or by shared harmful experience. The group intervention should follow the four phases and 20 steps in the Enright Process Model of Forgiveness with an age-appropriate forgiveness curriculum guide. As Freedman noted, the group mentality can have both positive and negative impacts [65]. Students can benefit from the adults and peers in the group, who model forgiveness, empathy, and compassion, so they develop healthier emotions and new insights regarding their suicidal ideation. An important lesson for group intervention is that, unless trust has been established in the group prior to the intervention, the participants are less willing to engage in meaningful discussions with each other, especially regarding confidential and personal information [66]. For those who may not feel comfortable discussing their suicide ideation or suicidal attempt with others, individual sessions should be provided as an option in addition to the group sessions.

Although group education is good for students’ sharing and support, as well as enabling them to see that they are not alone in their feelings [67,68], individually oriented forgiveness interventions with longer duration are more effective than shorter group interventions [52,67]. According to Skaar et al., students with deep hurts may benefit more from individual forgiveness counseling sessions [59]. Tier 3 aims to help the students who have the most serious suicidal ideation or suicide attempts. It is very likely they have experienced serious injustices in their lives. Tier 3 conducts more intensive interventions with more frequent, individual sessions because these students might require more time to work through the four phases of the forgiveness model. There are three noteworthy points in the individual counseling process. First, enough time should be allocated to build trust between the counselor or educator and the student to allow the individual to realize the injustice(s), and to acknowledge and express the emotions associated with the injustice(s). Second, the students may have difficulty recognizing inherent worth within themselves, as well as in the other person who has deeply hurt them. The educator or counselor should spend time listening to the individuals’ life stories, understand the causes of the psychological pain, and help students express emotions, as well as to recognize their own inherent worth. Third, if the students have experienced a severe injustice or a series of injustices, they may confuse forgiveness with excusing or condoning. It is important to help them distinguish what forgiveness is and is not, and to realize that forgiveness and justice can be sought at the same time. A goal is to help students think about the reasons why the other person offended, not to make excuses, but to better understand what had happened in that person’s life to cause them to perform such an injustice. This new insight and understanding can lead to feelings of empathy and compassion on the part of the victim toward the one who offended.

6. Conclusions

In conclusion, upon designing an intervention for suicidal adolescents, the first thing to keep in mind is to tailor the intervention to the developmental needs of adolescents who have suicidal thoughts and behaviors. FEI targets and deals with the most prominent risk factor in suicide, psychological pain—a mental condition that is associated with both teens’ emotional needs and cognitive characteristics. Implementing the three-tiered FEI in schools seems realistic as it aims to provide social emotional learning for a wider adolescent population in schools and, at the same time, target individuals with suicidal ideation and suicide attempts. The efficacy of the FEI model is worthy of future research and consideration, involving adolescents who are angry, depressed, and at-risk for suicide ideation. To test the effectiveness of the intervention at Tier 1 in the FEI model, randomized control trials (RCTs) could be used by randomly assigning classes (Tier 1) to the experimental or control condition [69]. The foreseeable barrier of using the RCT approach is that schools may not be able to afford the time required to be involved in a large-scale study. To minimize the burden, randomization at the school level could be considered by selecting one class from each school to participate in the experiment, while including many schools. A limitation is that even using the same curriculum, it is difficult to have control over confounding variables in schools. To test the effectiveness of the intervention at Tier 2 or Tier 3, a single case experimental design could be applied [66]. Some foreseeable challenges with this approach could be that (1) extensive interventionist training is needed for effective intervention; (2) the group dynamics affect students’ motivation and engagement; and (3) sufficient time is crucial to see effectiveness in the intervention. As students at Tier 2 or Tier 3 usually have experienced more injustice in their life, with more psychological pain, the most important issue is to allow them extensive time to go through the process of forgiveness.