September is National Suicide Prevention Month

September is National Suicide Prevention Month, with a particular focus September 5-11, which is Suicide Prevention Week. I wanted to offer some insights for parents about how to talk to their kids about suicide. The link below contains a ton of high-quality resources, and I encourage you all to browse those.

https://afsp.org/national-suicide-prevention-week

I also want to alert you to a Facebook Live event hosted by the American Foundation for Suicide Prevention, outlined in the picture below. It's a great place to ask questions to a live expert as well as to hear more about what you can do to minimize the risk of suicide in your community.

Below, I’ll highlight a few key essential points for parents and other caregivers to keep in mind when talking about suicide with their families (or with anyone, for that matter).

Avoid saying “successful suicide,” “committed suicide,” “suicide epidemic.” “Successful” communicates that suicide is a desired outcome. “Committed” makes suicide sound like a crime or a “sin,” and can alienate some people, especially teens. “Epidemic” sensationalizes suicide and is inaccurate.

Instead, describe suicide as a serious symptom of an illness, that illness being depression and other mood problems. You can talk to your kids about depression being a common illness that everyone feels to some extent, and you can also mention that suicidal thoughts or other thoughts about death are very common, occurring in practically everyone eventually, though at different levels. By normalizing suicidal thoughts, you open up the floor to talk about them just as your child would about any other symptom of illness, such as a fever or chills. Next, tell your children that mood problems and suicide are both treatable. Just like any other illness, there are things that can be done to manage or even eliminate the symptoms. Finally, tell them there are doctors who specialize in treating this illness and let them know how to access those doctors if they ever needed.

It’s important to look for opportunities to talk about suicide with your kids. If your kids see or hear about suicide on TV or in their real life, use this as a springboard for the above conversation about it. This shows them they don’t have to wait until they’re depressed to bring it up, and it makes it more likely they might tell you if they do have those thoughts.

It’s also important to respond in a calm and supportive manner if they do tell you they’re having suicidal thoughts. Show them they don’t have to be too afraid of the symptom and that you can both address the symptom together. Again, suicidal thoughts are very treatable and the majority of people that have them never attempt or die by suicide. Talk to them about seeing a doctor or therapist to help come up with a plan for addressing the symptom. If they ask about the hospital, remind them that most people with suicidal thoughts do not need to go to the hospital, but try to avoid making any promises that a hospital won’t be necessary. If they are worried about going to the hospital, remind them it is okay to be nervous, but that whatever happens will only be temporary and designed to help make things better. I’m including an old article below I wrote from the very first edition of the CAPTVRE Imagination Newsletter, from Summer 2017. The rest of the newsletter is linked here. This article reviews different levels of suicidality, which can give parents ideas about what levels of help might be needed. My child wants to die: Parenting a suicidal child

by Jason Steadman, Psy.D.

Here’s the ugly truth – youth suicide happens. According to recent studies, suicide is the 3rd leading cause of death for young people ages 10-24, and currently accounts for 20% of all deaths annually (that means 1 out of every 5 deaths results from suicide). There are gender differences too. Although girls on average attempt suicide more than boys, boys have a far higher rate of completion of suicide (meaning the attempt resulted in death). Of the 10-24 age group above that died from suicide, 81% of them were males! The reason for this difference is that males more often use lethal means when attempting (think firearms or jumping off of a cliff), whereas females are more likely to survive their attempts, because their attempts can be treated medically (think overdose or cutting). In my practice, I work with suicidal thoughts and behaviors quite frequently. Sometimes there is a need to be gravely concerned; other times, they are just fleeting thoughts with no real intent. These fleeting thoughts, in fact, occur so commonly that some data show that >80% of people will have them. Personally, I am more liberal. I believe that almost everyone – 99.9% of people – will at some point in their life have a thought enter their head at least resembles suicidal thinking. How many of you have ever said, “Oh please kill me now!” when forced to do something extremely boring or annoying? While saying “Kill me now!” may not have been a serious desire for death, it is a reflection of one of the complex, ugly sides of our humanity – an idea that some things are worse than death. And this idea is what leads to suicidal serious thinking! People come to genuinely believe that death is better than living.

In my current job, I teach/train future mental health professionals. A major part of that job is teaching them how to recognize various levels of suicidality. On the surface, these various levels seem simple, but make no mistake, we spend YEARS perfecting the art of evaluating (and treating) suicidality. So, please don’t try to use this column as a guide to decide if your own child really is at risk. Have them evaluated by a professional. It’s the safest, best thing you can do. Also, don’t worry about whether or not the child will be honest with us. We are also trained to handle that, and we’ll get input from you as parent/guardian as well. With that caveat being said, here are the various levels of suicidality, in order of relative level of concern:

1) Sarcastic hyperbole. Hyperbole are exaggerated statements or claims not meant to be taken literally (e.g. “I’m so hungry I could eat a horse.” “I’ve got a ton of paperwork.” – seriously, I hope no one ever has a literal ton (2000 pounds) of paperwork). So, in this example, the person is making suicide into a joke to express their dismay at something. “I’d rather slit my wrists than listen to you talk!” Many youth talk this way, with no air of seriousness whatsoever. Others, however, may actually be having suicidal ideation. Sometimes it’s hard to tell the difference. So, if you hear your youth talk about suicidality sarcastically, take a moment to assess the seriousness of it. And if you’re worried, bring them in to see a professional.

2) Morbid ideation. Morbid ideation simply refers to thoughts about death (in this case, one’s own death), but without those thoughts involving any self-inflicted harm. Examples of this include, “If a bus hit me while I was walking home today, I guess that wouldn’t be too bad.” Or “I hope I die in my sleep!” In both cases, there is a faint desire for death, but no desire to actually make death happen (when questioned, they say they don’t actually want to walk in front of a bus or don’t want to do anything to make themselves die). These thoughts are very common in depressed people, and do not warrant emergency intervention (e.g. hospitalization). Rather, they can be worked through in longer term treatment.

3) Suicidal ideation (without plan or intent). Similar to morbid ideation, suicidal ideation involves thoughts about death, but this time, the thoughts involve self-inflicted harm. The most basic example is “I want to kill myself.” Other examples may include imagining themselves jumping off a tall building. They don’t actually have to put words to their actions. Sometimes, just the image is enough. Like morbid ideation, these thoughts are common in many mental illnesses, but don’t mean a person needs to be hospitalized. However, someone with active suicidal ideation should ideally be seen for therapy at least once per week, and should not go more than two weeks without being seen, ideally, if possible. However, note that this frequency of services is not a hard and fast rule, and sometimes professionals may recommend more or less frequency, depending on the specific case.

4) Suicidal ideation with plan (but no intent). As it sounds, at this step, the person has developed a plan for how they would commit suicide. There are different levels of planning possible too, some very poorly hashed, others quite elaborate. In some cases, youth may have already taken some (or nearly all) of the steps in their plan, or they may not have taken any. Obviously, a plan but with no action is less concerning than a plan in which actions (steps) have already been made. But, in both cases, when a person enters the “planning” stage, they have entered a higher level of treatment need, including intensive treatment. Still, without intent, hospitalization is rarely necessary, and, instead, patients can benefit from intensive outpatient therapy (think >once weekly therapy), at least until their symptoms start to get better.

5) Suicidality with plan and intent. This is the highest level of suicidality, in which there is both a plan to commit suicide and an expressed intent to do it. This level occurs when a patient says, “I am going to kill myself.” Sometimes, they even tell you when and how they are going to do it, but whatever the details, an expressed intent is the highest level of concern and usually results in temporary hospitalization to provide safety. In some cases, a recent suicide attempt may have even already occurred. I have worked with a number of families where hospitalization has become necessary due to youth suicidal intent. Almost always, there is a concern with “what it will be like,” and worries about “I’m (or my kid is) not crazy. I (he/she) don’t (doesn’t) need a hospital.” Sometimes, there are even financial worries – “I can’t afford hospital bills.” These are perfectly normal thoughts and concerns, and they do not make one a “bad parent” for having them. It’s okay to be scared, because a lot is unknown about the hospital. A good professional will talk you through the steps and provide assistance throughout the process. However, try your best throughout to remember that we (as professionals) do not recommend hospitalization unless we are really worried about someone’s safety and that it is better to be safe and help your child get better than it is keep your child home and risk them killing themselves. In reality, very few hospital referrals result in long-term inpatient treatment for youth. In my experience, hospital stays (when there is real suicidal intent) last 1-3 days, after which youth are referred out for intensive outpatient treatment.

So, why does all of this matter to you as a parent. First, you should be aware that pediatric suicide is a real phenomenon and that there are different levels of concern, depending on how far along they’ve gotten in the above progression. Again, though, I can’t stress this enough, don’t try to be the expert yourself. While you likely know your child better than any professional ever will, many times youth will tell a professional things that they would never tell a parent, and that’s okay (see the 13 Reasons Why column for more on that). Next, it’s important to remember that children of all ages can have suicidal thoughts and behaviors. Okay, newborns can’t really have truly suicidal thoughts, that we know of – but newborns ARE at risk for self-harm, and we regularly do things to protect them from self-harm, because they can’t help themselves. We put little mittens on their hands to prevent scratches, we lay them on their backs at night to minimize suffocation risk, we plug electrical outlets, lock cabinets, etc. We do this willingly because we know babies can get themselves into risky scenarios that can hurt them if we don’t. Well, we can do the same with older children as well. If your child has any risk of self-harm, take reasonable protective measures. Now, this does not mean you should lock your teenager away in an empty, padded room, but it does mean that if they have suicidal thoughts, then it may be a good idea to lock away prescriptions, knives, and other weapons to minimize access to them, at least until they get better.

Additionally, young children can and do have suicidal thoughts. I once saw a 2.5 year old male who wanted to jump out of his third story window following the recent death of his father. In fact, it is often more concerning when young children have suicidal thoughts, compared to older children, because young children rarely appreciate the permanence of death. In the above case, this boy believed he would die, visit his father in heaven, and then come back to life as normal when he was done. So, he really did want to die (he had suicidality with plan and intent), but he didn’t really understand what death meant.[1] So, be alert to suicidal thoughts or behaviors even in young children, because they can be very serious.

The other thing to remember is that suicidality and depression are treatable mental illnesses. People get better, if we give them the time, opportunity, and treatment to do so. While you may not always go to the doctor if you have a little cold, waiting to see if it gets better on its own – it’s important to remember while, like a cold, some depressed thoughts are temporary, others are far more insidious, like a cancer. And like a cancer, they can grow inside of you, spread through your whole body, and they can kill you. But also, just like (most) cancer, depression is treatable. The treatment may take time and may not always be pleasant, but it is treatable.

For a useful review of additional warning signs and how you can respond to them, visit the following page: https://www.youthsuicidewarningsigns.org/

Additional help can be found at:

https://suicidepreventionlifeline.org

http://www.thetrevorproject.org/

To find referrals near you:

https://www.findapsychologist.org/

https://therapists.psychologytoday.com/rms

[1] If you’re curious, I did not have to hospitalize this child. Rather, we helped his mother take precautionary measures (locking his window in a way he could not open it; monitoring him closely). We also helped her learn a positive way to talk with her son about death to understand his father’s passing and process his bereavement in a normal, healthy way. In other words, this child did not have a mental illness, but he was experiencing a normal bereavement process, and just needed guidance through that.