Original Article
Spirituality, Adolescent Suicide, and the Juvenile
Justice System
Richard A. Wahl, MD, Sian Cotton, PhD, and Patricia Harrison-Monroe,
Background: Spirituality is often overlooked as a coping method
and resilience factor in the lives of adolescents. An improved
understanding of the role of spirituality in the lives of adolescents
will help in understanding the choices many teens face during
times of personal crisis. Youth entering the juvenile justice sys-
tem often present with high rates of mental health problems and
suicidal ideation.
Method: Two clinical vignettes of adolescents who exhibited sui-
cidal ideation while in juvenile detention are discussed.
Discussion: An understanding of the role of spirituality for an ad-
olescent in crisis can greatly enhance our ability to provide cultur-
ally competent care and offer meaningful support. This becomes
increasingly important as the juvenile detention population becomes
ever more diverse. Valuable information can be obtained by taking
a “clinical spiritual history” which enables clinicians to have a clearer
understanding of an adolescent’s worldview and provide the neces-
sary therapeutic interventions. Specific questions are suggested as a
basis for obtaining this information.
Key Words: spirituality, delinquency, violence, juvenile detention
S pirituality is often overlooked as a coping method and
resilience factor in the lives of adolescents. The need for
such support seems to be increasing as violence becomes an
ever-present reality in the daily lives of many adolescents.
Violence is evident in the content of entertainment media
viewed by teens1 and by the frequent news reports of juvenile
gang activity in American urban areas. Criminal activity by
From the Department of Pediatrics, University of Arizona, Tucson, AZ;
Departments of Family Medicine and Pediatrics, Institute for the Study of
Health, University of Cincinnati Academic Health Center, Cincinnati,
OH; and Department of Psychiatry, University of Arizona and Director,
Behavioral Health Services, Pima County (AZ) Juvenile Court Center,
Tucson, AZ.
Identifying information has been changed for the adolescents in both vi-
gnettes.
Reprint requests to Richard A. Wahl, MD, Department of Pediatrics, Uni-
versity of Arizona, 1501 N Campbell Avenue, Tucson, AZ 85724-5073.
Email: rwahl@u.arizona.edu
Accepted March 24, 2008.
Copyright © 2008 by The Southern Medical Association
0038-4348/0⫺2000/10100-0711
Southern Medical Journal • Volume 101, Number 7, July 2008
PhD
adolescents often results in detention under the jurisdiction of
the juvenile court system. It is within juvenile detention that
many delinquent adolescents receive their primary medical
and mental healthcare, and where interventions to break the
cycle of violence are possible.
An improved understanding of the role of spirituality in
the lives of adolescents will help in understanding the choices
many teens face during times of personal crisis.2,3 Placement
in a juvenile detention facility is often such a time of crisis.
The added stress of the juvenile detention environment causes
many adolescents to consider self-injury. Suicide is the lead-
ing cause of death within juvenile detention centers.4,5
In this article, we will explore the role of spirituality
within the juvenile detention system. We believe that an un-
derstanding of spirituality in the life of an adolescent can
enhance behavioral health interventions for detained juve-
niles and provide resources to enhance adolescent resiliency
for teens in crisis. We will examine the specifics of two
case studies2 that demonstrate the importance of under-
standing an individual youth’s sense of spirituality within
the context of suicidal ideation and the juvenile justice
system. Recommendations will be made on how clinicians
can integrate a spiritual assessment into clinical practice
and, more specifically, into the mental healthcare treat-
ment of adolescents in detention.
Key Points
• A “spiritual assessment” may be useful in the mental
health evaluation of adolescents in crisis.
• Practitioners need to be aware of the various religious
and spiritual traditions represented by today’s adoles-
cents to most effectively diagnose and treat mental
health problems.
• Addressing the spiritual concerns of adolescents has
both benefits and risks.
• Clinicians have an ethical obligation to provide cul-
turally competent care, including an awareness and
willingness to incorporate spirituality if indicated by
the needs of their patients.
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Wahl et al • Spirituality, Adolescent Suicide and Juvenile Justice System
Case Vignettes
Marco
Marco, a 16-year-old Native American boy, was detained
on charges of driving under the influence, resisting arrest, and
driving without a license. On intake, Marco reported a brief
counseling experience two years previously but could not
remember why. He denied ever having been on psychotropic
medication. When asked about recent losses he reported the
death of a close uncle two months previously and losing
touch with his best friend since he and his family moved off
the reservation. He stated he was “a little sad,” but preferred
living in his new apartment. On the third day of his detention,
during a routine interview with a clinician, Marco complained
of poor sleep due to the appearance of his dead uncle. Marco
explained that his uncle’s spirit was repeatedly motioning
toward him, which Marco interpreted as a sign that he should
join his uncle in the afterlife. The clinician tried to elicit
further information and details of a suicide plan, but Marco
refused to answer any further questions. Marco was moved to
an observation cell, placed on high-risk suicide watch, and
scheduled to see a psychiatrist. Detention officers reported
frequently observing Marco appearing to respond to internal
stimuli. Contact with his family was of limited help, as they
concurred with Marco’s perception that his uncle appeared to
him for a reason and would not give consent for medication.
Marco refused to participate in any unit activities and re-
mained strong in his resolve to find a way to kill himself.
After a week of close observation, a decision was made by
detention administration and behavioral health staff to bring
in a spiritual healer from Marco’s tribe. The behavioral health
staff understood that they lacked the cultural credibility that
the spiritual healer possessed. Marco felt that the non-Native
staff at detention were trying to trick him into abandoning his
beliefs. The healer was allowed to conduct a lengthy cere-
mony with Marco, and reinterpreted the appearance of the
uncle’s spirit as beckoning him to stop engaging in criminal
activity and to “come back” to his family. Marco respected
the tribal healer enough to be able to accept that interpreta-
tion. He no longer reported seeing his dead uncle and was
able to come off suicide watch within a few days. Marco did
not display any further psychotic or suicidal behaviors during
his month-long detention.
Yvette
Yvette, a 14-year-old Hispanic girl, was brought to de-
tention after running away from her group home with another
girl one month earlier. Yvette and her siblings had been in
child protective custody for the past five years, when her
father committed suicide and her mother abandoned the fam-
ily. This was Yvette’s eighth arrest and her fifth detention.
Her behavior during previous detentions was marked by ag-
gressive acting out. Yvette was in poor physical condition
712
upon arrival at detention after living in the desert for the prior
month. She had multiple cuts and contusions and was mini-
mally cooperative with the nurse tending to her wounds. She
appeared very angry and became physically combative during
a routine search. She required brief physical restraint during
intake screening while a mental health clinician tried to calm
her. After lunch that same day, Yvette participated in a poetry
contest and fully cooperated with detention staff. The next
morning, detention staff requested a mental health review for
Yvette, as she had written extensively about suicide and death
in her two poems. A clinician evaluated Yvette and placed
her on a high-risk suicide watch, despite her tearful assur-
ances that this was just fantasy. A few hours later, she re-
vealed that she had prayed to die during her time in the desert
and thought of killing herself almost daily. Yvette stated that
she now felt very remorseful, as she believed suicide to be a
sin and that her father was in hell for killing himself. She then
requested to speak with the detention chaplain. Over the next
five weeks, while a new group home placement was sought,
Yvette spent time with the chaplain on a daily basis, and was
able to begin to verbalize a desire to change parts of her life.
Yvette’s suicide watch level was gradually reduced, and she
was evaluated for mood stabilizing medication. Yvette has
had only one subsequent brief arrest, and has since not re-
turned to detention. She has kept in contact with both the
chaplain and the mental health clinician over the past three
years. Yvette credits the support she received while in “the
bad place in my mind” for staying out of trouble.
The experiences of Marco and Yvette demonstrate the
importance of understanding the spiritual concerns and per-
spectives of adolescents. For both adolescents, appropriate
therapeutic interventions required taking into account their
spiritual worldview. Each adolescent was able to make a
significant “cognitive shift” in his or her perspective once
their spiritual concerns were understood and addressed. While
it may not always be the case, an understanding of the “world-
view of the patient” often includes aspects of spirituality. The
increasing diversity of religious and cultural backgrounds of
adolescents in juvenile detention reflects the increasing di-
versity of the U.S. population. Practitioners need to be aware
of the various religious and spiritual traditions represented by
today’s adolescents to provide appropriate diagnosis and in-
tervention.
Mental Health Disorders within Juvenile Detention
Youth entering the juvenile justice system often present
with high rates of mental health problems that can range from
mild adjustment disorders to severe affective and thought
disorders.6 As with jails and prisons serving the adult popu-
lation, juvenile correctional facilities are becoming de facto
mental health hospitals. One of the largest studies to date of
psychiatric disorders in detained juveniles found that nearly
two-thirds of males and three-quarters of females met diag-
© 2008 Southern Medical Association

nostic criteria for one or more psychiatric disorders. In addi-
tion, one half of the youth in this study also had a substance
abuse disorder.7 Mental health disorders and substance abuse
have been identified as the most significant risk factors for
suicide among adolescents.8 While suicide is the third leading
cause of death among all 15 to 24-year-olds,9 it is the leading
cause of death for adolescents in detention.4
Lessons learned from Marco
Studies of the prevalence of suicide among Native Amer-
ican populations have revealed rates as high as 15 to 30%,
and the rates of completed suicide are more than 70% higher
among American Indians than among the general population.
The relationship between traditional Native spiritual beliefs
and risk of suicide is complex, as aspects of this spirituality
may or may not decrease suicide risk.10 –12 As demonstrated
by Marco, aspects of Native American spirituality may be
incorporated into an adolescent’s suicidal ideation, or may
assist an adolescent in getting through stressful life events.
Various authors have looked at the importance of under-
standing spirituality from a Native American perspective in
understanding the role it plays in suicidal ideation among
Native youth.
Garroutte12 examined the impact that three separate mea-
sures of spirituality demonstrated on the suicide rate among
reservation-based members of a northern plains tribe. The
three measures were: commitment to Christianity (“How im-
portant are Christian beliefs to you?”), commitment to tribal
spiritual beliefs (“How important are tribal spiritual beliefs to
you?”), and a separate measure of tribal cultural spiritual
orientation, as measured by eight questions (such as “There is
balance and order in the universe” and “I am in harmony with
all living things”).
In this survey of 1456 tribal members aged 15 to 57
years, Garroutte found that neither Christian beliefs nor spe-
cific tribal spiritual beliefs proved protection, while embrac-
ing a Native spiritual orientation outside of specific religious
beliefs was associated with a significantly reduced rate of
past suicide attempts.
As related to Marco, a clinician might encourage him to
discuss his spiritual orientation. This would include how he
believes his life fits into the larger world, what his ancestry
has taught him, and how his life is an extension of those
before him. Coupled with a discussion of his current life
circumstances and struggles with suicidal thoughts, these con-
versations may help Marco connect with his own spirituality
in a way that is internally motivated and enduring.
Yoder’s10 study of suicidal ideation among American
Indian adolescents found that “enculturation” (which included
involvement in traditional spiritual activities) was the most
significant protective variable, while substance abuse and per-
ceived discrimination were the most significant risk factors
for current suicidal ideation.
Southern Medical Journal • Volume 101, Number 7, July 2008
Original Article
EchoHawk11 stressed the difficulty in identifying a sin-
gle cause of the high rate of suicide among Native American
adolescents, but noted that substance abuse was a factor in
90% of the completed suicides in her study. She stressed the
need for culturally sensitive approaches to remove the barri-
ers that prevent Native youth from receiving adequate mental
health services.
In the case of Marco, the importance of culturally rele-
vant mental health services cannot be overstated. For many
adolescents, as with Marco, this includes the relevance of
spiritual beliefs as they relate to one’s origin and family his-
tory. The “story” that Marco tells of himself as related to his
ancestors is powerful, and can be used to facilitate healthy
images of himself and pride in his future.
Clinicians have an ethical responsibility to assess behav-
ior within a culturally relevant framework, no matter how
seemingly “diagnostic” that behavior otherwise appears to be.
It is within this cultural context that they must acknowledge
the limits of their expertise. The clinicians in this case acted
professionally and responsibly by recognizing the immediate
danger Marco posed to himself and intervening quickly. They
attempted to elicit his family’s support and came to the real-
ization that a spiritually focused intervention might be more
appropriate.
Lessons learned from Yvette
Yvette’s is sadly a “classic” story in our juvenile deten-
tion system. Her history is plagued by abandonment, loss, and
struggle leading to mental health issues, self-injurious behav-
iors, and desperation. Yvette is part of a somewhat surprising
trend over the past 25 years, which is the increasing presence
of adolescent girls within the juvenile justice system. The
percentage of juvenile detainees who are female has increased
from 20 to 30% during this period. The nature of crimes
committed by females has become increasingly violent, with
the proportion of females who are detained for aggravated
assault increasing from 15 to 25% over the past 25 years.
While the overall rate of juvenile violent crime is at its lowest
level in 20 years, violent crimes committed by females have
actually increased.13
The growing number of adolescent girls entering the ju-
venile justice system presents an additional challenge, as ap-
propriate gender-specific programming and mental health ser-
vices are lacking in most jurisdictions. Girls often present
with more severe behavioral and emotional problems result-
ing from a high incidence of past sexual, physical, and emo-
tional abuse. Past sexual or physical abuse increases the risk
of both suicidal ideation and behavior in detained adolescent
females.14,15 Detained girls have very high rates of diagnosed
psychopathology. A 2004 study of detained adolescent fe-
males found 91% were diagnosed with conduct disorder, 85%
with substance abuse, 55% with depression, and 37% with
post-traumatic stress disorder (PTSD). Among the girls with
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Wahl et al • Spirituality, Adolescent Suicide and Juvenile Justice System
PTSD, 70% had a past history of sexual abuse. In addition,
78% of all detained girls fulfilled criteria for three or more
psychiatric disorders.16,17
The inherent stress of detainment can also lead to an
exacerbation of symptoms in adolescents with mental health
issues, as noted during Yvette’s detainment. Some stressed
minors, previously undiagnosed, may begin to display in-
creased symptoms requiring psychiatric intervention. This
may result in increased agitation or aggressive behavior,
which can lead to infractions of detention rules, punitive con-
sequences, and in some cases even additional criminal
charges.
The importance of chaplain services in a juvenile deten-
tion setting was described by Hausmann,18 who noted im-
proved outcome measures as a consequence of the availabil-
ity of pastoral counseling for those adolescents who requested
these services. Pastoral services can provide a cost-effective
way to extend behavioral healthcare in this environment.
Yvette’s request to talk with a chaplain came as some-
what of a surprise, as was the importance that her faith proved
to be as a source of support. It leaves one wondering what
might have happened if a provider had asked her earlier in her
life what role faith played, and whether she wished then to
have pastoral counseling. Unless we are routinely screening
for “spiritual struggles” (eg, “I feel like God has abandoned
me”) we may be missing a key opportunity for intervention
that could be relevant and, in Yvette’s case, potentially life-
altering.19
Role of spirituality within the juvenile justice
environment
Many factors influence an adolescent’s adjustment to
adverse situations, including personality, socioeconomic sta-
tus, cultural context, and gender norms. Faith and a sense of
meaning in life have been identified as essential to positive
adolescent development and adjustment.20,21 Spirituality in-
corporates a sense of meaning and purpose that may or may
not be aligned with formal religious belief or practice.22,23
Adolescents who have higher levels of religiosity and
spirituality fare better than their less religious or spiritual
peers. They have fewer mental health problems, lower rates
of high-risk health behaviors, and utilize spiritual coping re-
sources to manage physical illness.24 An estimated 84 to 95%
of adolescents believe in God, 80% state that religion is im-
portant in their life (39% say “very important”), 93% believe
God loves them, and over 50% attend religious services at
least monthly and participate in religious youth groups.25–27
The case studies of Marco and Yvette demonstrate how
an understanding of an adolescent’s sense of spirituality pro-
vides insight into their behaviors during times of crisis and
may inform interventions. As noted by Pargament,19 faith
during a crisis can assist an adolescent in recovering mean-
714
ing, control, and self-esteem. An understanding of an adoles-
cent’s spiritual worldview enhances our ability to intervene
during these crises.
An approach to “clinical spiritual assessment”
Marco and Yvette also demonstrate the importance of
obtaining a “clinical spiritual history.” While this has been a
long-standing component of pastoral care within healthcare
facilities, clinicians should be comfortable soliciting this in-
formation.
Marco and Yvette presented issues involving spirituality
in the context of their mental health interviews. Providers
need to be sensitive to patients who themselves feel these
issues are important, and be in a position to competently
undertake a spiritual assessment.
Several recent publications have discussed the details of
obtaining a clinical spiritual history. Koenig has provided
valuable instruction in “spiritual history taking” within the
context of adult patients.28,29 Houskamp30 has provided spe-
cific questions to assess the role of spirituality in adolescents:
1. Do you practice a religion? How?
2. Do you believe in God or a Higher Power? How do
you experience this power in your daily life?
3. Are there spiritual practices that you follow regularly?
Tell me about them.
4. In what ways has spirituality been important to you?
5. What things are most important to you? What gives
your life purpose and meaning?
6. Describe the worst moment in your life. How did you
cope with that experience?
Addressing the spiritual concerns of adolescents has both
benefits and risks. It is hoped that addressing these issues will
improve the adolescent’s ability to cope with stress and emo-
tional turmoil, with the quality of the provider-adolescent
relationship, and with compliance with treatment recommen-
dations. Unintended consequences are also possible. Address-
ing issues of spirituality must be done within a culturally and
developmentally appropriate manner. An adolescent who
closely follows a faith different from that of the clinician may
feel threatened by the questions, as might a nonreligious ad-
olescent. Also, the clinician must feel comfortable responding
to issues raised by these questions, and should have available
the needed resources from both pastoral and mental health
providers.29
Conclusions
The role of spirituality to enhance an adolescent’s ability
to cope with stressful life situations is often underappreciated,
especially in the context of mental health services within a
juvenile detention environment. An understanding of the role
of spirituality for an adolescent in crisis can greatly enhance
our ability to provide culturally competent care and offer
© 2008 Southern Medical Association

meaningful support. This becomes increasingly important as
the juvenile detention population becomes ever more diverse.
Valuable information can be obtained by taking a “clinical
spiritual history” which enables clinicians to have a clearer
understanding of an adolescent’s worldview and provide the
necessary therapeutic interventions.
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