The Topic That is Most Hard to Talk About, Yet Most Important

I’ve been experiencing a theme the past few weeks in my supervision meetings.  It’s showing up in individuals and groups, with supervisees/consultees who are new and those who are more experienced and practiced. 

The topic of suicidality and what to do when your young client (child or teen) discloses they are having suicidal thoughts or have made an attempt. 

This can be such a scary experience to witness with an adolescent, and clinicians can often feel they hold all of the responsibility in keeping their client safe. 

We all are going to go through this at some point with a client, so if you are a newer clinician and you haven’t’ yet experienced this, save this and come back to it for some support.

Suicide is such a hard topic to talk about.

For everyone!

Adolescents struggle to disclose when they are having suicidal thoughts due to fear.  Many times, that fear is due to multiple experiences of not feeling heard or held with this very difficult and scary thought.  For some, they’ve had multiple hard experiences with professionals and hospitalizations which can be a traumatizing experience.

They are also scared that others cannot hold their state of mind and are fearful of talking about their experience due to others capacity. They feel like they are too much of a burden to those who love and care for them. 

When parents are afraid to talk about it

It can often be because, well, when you talk about something this serous it makes it real.  Often, you will hear a parent speak about the child/teen expressing suicidal thoughts “for attention”.   Sometimes parents fail to take it seriously or take it so seriously that they may be activated and involve too intensive of an intervention out of fear.  (Understandably so…)

I challenge you to dig further when the idea of attention-seeking comes up in sessions…it will. 

Here is a way you can explore this with the parent:

“I wonder why your child might feel they need to harm themselves in order to get your attention?” 

What’s the need underlying that extreme/impulsive behavior?

I have worked with adolescents early in my career who would harm themselves impulsively when they didn’t get a need met and it would develop into a pattern.  Parents would be afraid to enforce rules or avoid conflict out of fear. 

When this occurs, adults can often be desensitized to the behavior and not take it seriously or say things that add more shame. 

Clinicians sometimes spend so much time, once a client discloses suicidal thoughts/ideas/plans on safety planning that not much progress is made in treatment.  It can become a pattern of focusing on our fear of keeping a person safe versus going beneath the symptom or behavior and seeing what the underlying need is. 

If we look at suicidal ideation as a symptom or behavior, we can give permission to really explore and find what is driving it. 

Think about it like this

If you are having daily headaches and your doctor asks you each visit to discuss if you are continuing to have daily headaches and how severe they are, then spends the remainder of your visit reviewing the plan for maintaining your headache and medication to treat your headache, you are never getting to the root of the problem. 

You would want your doctor to assess further.  What is causing your headache? 

I am encouraging you to assess further.

What is causing the suicidal ideation? 

What is the need?  Can we meet the real need?

When I work with clinicians in supervision and consultation, we spend time exploring and assessing the underlying need of the client.  When it comes to suicidality, I want to challenge you to go beneath the symptom and find out where it’s rooted. 

What’s leading this part of them (Internal Family Systems language) to believe ending their life would be better than being here?

What is the need?

Is it connection?

Is it acceptance?

Do they feel misunderstood by most people in their life?

Are they in need of a sense of agency in their life or control over something?

Do they need to experience felt safety?

Are they seeking to be unconditionally loved from someone?

Something in this adolescent’s life is driving a protector inside of them that is presenting this option as an escape from the hard experience they are enduring. 

Does it make sense to you (the clinician) that they would want to escape?  Why?

Here are a few ways I reflect with the client when suicidality is present:

• “Part of you feels like everyone would be better off if you weren’t here.”

• “Part of you feels suicidal.  Based on what I know about you, (label what you know) I can see how you may be experiencing such difficulty thoughts.”

• “This must feel very scary for you, I am going to be here with you as we figure out a way to help you stay safe.”

• “Things feel very hopeless right now.  I wonder if you can notice where you feel that hopelessness in your body?  What does it feel like?  Heavy?  Sharp?  Dull?  Tight?  How big is that feeling?  Does it feel hot, warm, cold when you focus on it?  (If you are EMDR trained, this would be a time where you could focus on that somatic sensation and engage them in BLS as they notice that feeling.)

Here are some prompts to explore deeper using Sandtray Therapy or Expressive Art:

• “I wonder if you could show me somehow what this feels like for you.”

• “I wonder what safety would feel like for you.”

• “I wonder what that part of you needs to feel _____(loved, wanted, accepted, understood).”

• “I wonder what life would look like for you if you felt _______ (build on prompt above).”

• “Are there any safe people in your life you could surround yourself with.”

• (If you are IFS informed) “I wonder if you could create an image of this part of you that holds these suicidal thoughts.”

·      Then spend time connecting with this part while helping the client connect with themselves.  (Clients with Dissociative Identity Disorder may show up as that part of themselves in session versus feeling they can connect to that part they become that part.  When this occurs, you have direct access to that part.)

This might look like:

·      How old does this part feel?

·      What does she like to do?

·      Does her voice sound like yours or someone else?  Is it familiar?

·      Is she here with you now?

·      What is she saying to you now?

·      What do you think she needs us to know?

·      What does she need?

·      How can we help her feel safe?

Connection is the deep need

The Deeper we can connect with our clients who experience suicidal thoughts, the stronger that felt safety becomes and their capacity to stay a little longer increases. 

You may be the safest person in this adolescent’s life right now.

Can we help to build their capacity to stay here a little longer?  Can we create enough felt safety that they commit to doing the work to feel better?

Disclaimer: If someone is actively suicidal and cannot be kept safe with the support of their therapist and family, hospitalization is the next step.  Active suicidality means the client has a plan that is fatal, means to complete the plan, and intention to complete the plan. 

Working with clients with suicidality can feel heavy for clinicians.  Seek support through your colleagues or supervision/consultation when needed.  Actively practice your own self-care following these sessions, between sessions, and at the end of your workday.

Quick and simple ways to engage in self-care throughout your day

Lay on your back with legs flat against the wall

Take 10 deep breaths

Spend 1 minute searching for your favorite color

Gaze out a window for 2 minutes

Step outside and breathe in fresh air, listen for sounds of nature, feel the breeze. 

Find someone to help hold your fears and anxiety. 

If you are wanting support thinking through cases like this, I offer supervision and consultation groups for clinicians working with children, parents, and trauma. 

You find more information here.

From my playroom to yours,

Dayna

P.S. I have some freebies I am working on.Like this one if you missed it.One is a cheat sheet of treatment goals and objectives specific to EMDR and Play Therapy. Be looking for this in your inbox soon. The other is videos of scripts to use with clients. If you find you are seeking something specific, let me know if the comments and I will work to create it for you.

P.P.S. If you know other clinicians who could benefit from my expertise, show me some love and share away.