Five minute read

Hearing a child or youth say that they want to die can be a scary experience for any behavioral health professional. When I was a newly minted BHC, I found myself in a complex juggling act of supporting my medical team, taking my patient’s suicidal ideation (SI) seriously while understanding variations in severity, and coaching distraught families through complex emotions.

I also learned it was important for me to recognize my own feelings that bubbled up in response to hearing a child voice SI, which struck me differently than when I worked with adult patients. With all these moving parts present, I am still learning how to best support, instruct, and normalize these often intense and complicated scenarios.

Supporting the Medical Team

I have seen a range of emotions in my various medical teammates when a patient voiced that they were suicidal. Some were panicked, while others were deeply concerned and still others were a bit dismissive.

The word suicide has such a charged connotation that depends on so many factors. One’s upbringing, religious beliefs, and personal life experiences all shape how one views this  societal taboo. Therefore, my main goals with my medical team are to 1) understand that those conscious and unconscious beliefs about suicide are present within them and will most likely remain unknown to me as I am their teammate and not their therapist; and 2) remove the taboo by normalizing the desire to die.

Please don’t mistake me. I don’t want anyone to choose their own death over life, but I do acknowledge that death is always an option. I do my best to reframe the “desire for death” as a desire to be free of pain because when situations are painful, it is normal to want an “out.” Pile on familial issues, developmental issues, societal issues, and oh my! It’s a miracle we’re all still functioning.

Throw the fact that it’s a child voicing SI and one’s mind tends to go to the worst-case scenario. Is the child being abused? Neglected? Or are they “crying wolf” and putting their family through the wringer? It’s likely that what and how a provider was reporting during their warm handoff clued me into more about how they feel about the situation rather than what was actually going on.

My job then was to suss out how frequent, intense, and severe these SI feelings were. Are they passing clouds or daily thunderstorms? Do we need an emergency detention or a crisis response plan? Ultimately, I presented my team with a supportive sounding board that listened with an inner ear for details, not only of how the medical team member is processing a statement of SI, but also an out voice that reassured them that there are resources and actions that can be taken to work toward a patient’s safety. But first I needed to get more information from patient and then report back.

Patients’ and their Families: The Intricate Dance

As someone who grew up with depression and anxiety, it is easy for me to empathize with the pain of children. I feel like their natural ally, coming from a space of understanding, curiosity, and neutrality. Parents, however, arrive with all levels of understanding, curiosity, and neutrality. While some have openly wept, others have yelled or stayed silent and aloof. Most often, when I speak with a parent and child or an entire family, there is a palpable level of concern coming from parents and guardians.

On some occasions, I speak with just the child alone, usually when they either clam up around their family or there is a large amount of hostility or lack of authentic communication. However, working with the family as a unit is what I most prefer, and it is easier to make sure that everyone is on the same page at the end of the visit.

First, I echo what their provider shared with me, that the kiddo was voicing thoughts and feelings about dying or killing themselves. Phrases like, “I don’t want to be here anymore,” or “Things would be better off if I weren’t here” or “I’m just a burden” are more common than outright, “I’m going to kill myself with x on y day.”

Using a combination of support, emotion regulation and distress tolerance tools, and visual metaphors, helps patients and families

Once the patient and guardian confirms these thoughts and feelings are present, I take them through my set of testing the temperature questions that most BHCs are familiar with (i.e., how would you kill yourself, when, where, have you tried killing yourself before etc.) while sprinkling in a few more questions for my understanding. For example, “what would killing yourself do for you?” and “How old are these thoughts?” and “If you had to cast and actor or character from a movie or TV show to be the voice of these thoughts, who would you cast?”

Once I have a solid idea of how these thoughts sound and what they are doing for kiddo, I check-in with the guardian for their level of understanding. Most parents are unaware of all the dimensions of their children’s pain and it is helpful for them to hear about it in a different context. From there, we work on a crisis and safety plan and make any appropriate referrals.

It has been almost nine months since most children came home for spring break and then never returned to a regular school schedule due to the COVID-19 pandemic. The increased time in close quarters with their families, the added confusion of adapting to online school, and the lack of social interactions with friends increased the suicidal thoughts and feelings in many patients who already struggle with distress tolerance.

Using a combination of support, emotion regulation and distress tolerance tools, and visual metaphors, helps my patients’ families to conceptualize what and how they are feeling and steadily work toward wanting to live life instead of escape pain.