Terror, anger, confusion, anxiety, and desperation are some of the feelings that family members express following a suicide attempt by a young adolescent. The mental health worker who has been working with the teen may be left to wonder – “What did I miss? What didn’t I do? What didn’t I see? What more could I have done?” The worker may have just seen the client in his or her office a day earlier when everything seemed like it was going well. It probably was going well.
A “normal” adolescent’s feelings are often changing; there are shifts in mood and rapid transitions from impulse to action, without pause for reflection or time taken to consider consequences. The decision to act without thinking is similar to the process of relapse to drugs and alcohol. Suicidal attempts often occur when a quick answer or rapid resolution to feelings is not immediately available. The option to “end it all” in the snap of a finger can feel, momentarily, like a viable option; a quick solution to help one to “cope” with immense and intense feelings. The following practice examples illustrate different cases (names and other identifying information are disguised).
A confused and distraught mother, Mrs. A., telephoned her family’s therapist to report that her 14-year-old daughter, Carly, had attempted suicide the night before. Mrs. A’s, in tears, says, “I was just beginning to trust her again, I thought things were getting better.” “What happened?” asks the therapist who was in shock herself, thinking, “I just saw Carly and there were no signs of distress.”
Mrs. A. noted, “She looked fine, I permitted her to go out with her friends to a party with adult supervision just like we discussed in our meetings. She came home after the party and looked a little upset. But I didn’t think much about it and so I went to bed. When I woke up, I discovered her lying on the living room floor. I thought that she had just fallen asleep. When I tried to wake her up, she appeared sluggish. I realized something wasn’t right. She admitted to taking some pills she found in the bathroom. They were my pills. I called the police and they came and took her to the hospital.” “How is she now?” the therapist asked, fearing the worst. “She is ok. The hospital is going to keep her.” The therapist is extremely relieved, but is thinking to herself, “What happened? What did I miss?” Although Carly had a troubled history, including witnessing violence in the home, mother and daughter had been committed to learning how to recognize triggers and scenarios that could escalate to violent outbursts. So, what happened?
Living for the Moment
Many teenagers live for the moment. They want to be with their friends to share their thoughts and feelings, the good and bad, the highs and lows. Teens who report suicidal ideation may be suffering from depression and feelings of hopelessness or worthlessness. They may also be experiencing a wide range of emotions. When there is a history of trauma and violence in their lives, they are likely to have difficulty coping with conflict. When taking action to end one’s life, a teenager may think that this is the only option he or she has to change things.
Nevertheless, the desired outcome for the distressed teenager may not be to die, but to find relief in the moment. From a counselor’s logical perspective, it seems as if it would be simple enough to teach an adolescent client who fits this profile to understand that feelings change, and that if they can just learn how to “chill out” they can get past their intense bad feelings. But for some teenagers, like Carly, who was distressed and feeling intensely at the moment, it is a black-and-white, all-or-nothing-at-all proposition when it can feel like life and death are in the balance.
Carly originally came for counseling following a big blowup with her mother. The argument was over a relationship that her mother disapproved of and that Carly could only maintain by being deceptive. Carly’s suicide attempt came in the aftermath of a fight with her boyfriend that fractured the relationship and left her feeling the pain of unbearable loss.
In order to work with an adolescent client who has recurrent feelings of desperation, the therapist must have the confidence to allow them to “have all their feelings” in the privacy of their therapy meeting. They must allow their young clients to talk about their thoughts of death and what that means to them, and help them to openly express the fact that sometimes death feels like a viable choice to them, then help them to see that there are better options to explore. We need to help our young clients to be in the moment with their despair and desperation, then help them to discover and embrace their strengths. This is a delicate dance that requires courage and patience by both parties.
A Delicate Dance
One morning sometime after the events described above, when the social worker arrived at her office, Mrs. A. and Carly were sitting in the waiting room. Mom was beside herself, stating that her daughter lied and was defiant, and that she couldn’t live with her for another day. She demanded, “Put her in the hospital!”
The worker was confused. She thought things had improved. Nevertheless, she made an assessment and determined that Carly was not suicidal. Carly said, “I don’t want to kill myself, but I hate that my mom loses control and gets upset so easily. This time instead of swallowing pills, I decided to leave the house and I stayed out all night. I slept in the playground around the corner from where we live. I do not want to go to the hospital, I am not crazy and I do not want to kill myself. But, I don’t want to be around her (mother) because of how we fight. I am not going to a hospital.”
It took the better part of a day to arrange for an alternative to a hospital referral. The work included another assessment, this time by the team psychiatrist, to validate that Carly was not suicidal. There was much consultation, many phone calls and a good deal of careful planning. It was determined that if Carly could not go home with mom, that a temporary respite placement was a viable and less expensive alternative to psychiatric hospitalization. During the course of evaluation, we discovered that the daughter’s behavior was inducing mom’s own vulnerabilities and feelings of desperation that went back to her own difficult growing-up years.
The work following the week-long respite was entirely focused on strengthening the relationship between mother and daughter. Carly learned alternatives to being impulsive when she felt desperate, anxious and angry. To affirm what she was learning, she would say “I know what not to say to my mother not to set her off” and “I don’t want to argue and fight anymore.”
Advocating for an alternative educational placement to help her with some of her learning deficits was also a major accomplishment. Encouraging Carly to keep active after school was important as well, so she would not have to be caretaker for her younger siblings. She found a part-time job and joined the girls’ field hockey team.
It has been several months since respite and the family is now ready to end treatment. Will there be new episodes of violent outburst? Will there be other crises to resolve? Maybe. But Carly has learned ways to cope that are alternatives to suicide.
Conclusion: “I am in pain but I am willing to change.”
When working with an adolescent who attempted suicide it is important to keep a few principals in mind. Although this is by no means a complete list, it will provide some direction.
(1) A suicidal gesture is a crisis that is an opportunity for change and growth. The crisis offers the therapist and client (family) the chance to explore dynamics that led to the suicidal “dangerous act.” It offers the opportunity to better understand the adolescent’s belief system regarding what he or she thinks would be the impact of their death. The therapist can bring reality testing to the discussion. Teenagers, during this development stage, often think that the world revolves around them and their friends. (see number 3, below, for illustration).
(2) The therapist must form an alliance with the adolescent and her or his parents. The therapist must gain the trust of both the adolescent and parents. This is a balance that requires persistence in the early phase of treatment. If the adolescent believes that the worker is aligned with her or his parents, they will be likely to withdraw. If the parents think that the worker is favoring their child’s perspective, the therapist will lose respect from the parents. The therapist must establish trust and mutual respect with both parents and child. The parents must feel that the therapist understands their frustration, anxiety, fear and anger. The crisis offers an opportunity for the parents to explore how their behavior may have impacted their child. A solid relationship with all family members enables the therapist to give strong directives, if needed, during critical periods. For example:
Mom: “Take her; put her in the hospital….” (She is really saying, “I can’t do this anymore, I don’t want to hurt her or for her to hurt herself. Help me do it differently.”)
Social Worker: “No not the hospital, but I understand we do have to do something different. Trust me, the hospital and the police are not the answer.”
The therapist must be comfortable entering the family system. Understanding the communication style and patterns between the parent and child takes time and patience. The motivation for change must come from the family.
(3) Adolescents need guidance in seeking alternatives to suicide. Help the adolescent identify reasons for living that she may not have considered before. Help them to discover and make alternative choices to suicide next time intense feelings surface and start to build. Raise awareness of reasons for living that she may not have thought about before. For example:
Social Worker (SW): “What makes you want to kill yourself?”
Young person (YP): “My mother will suffer. She doesn’t want me, so there, I won’t be around.”
(The social worker has made a deliberate choice not to challenge this since the girl and mom have so much conflict. This is a theme that will require ongoing work, but the social worker is helping her to seek reasons for living.)
SW: “What about other people, will anyone else miss you?”
YP: “I don’t know, and I don’t care”
SW: “What about your little brothers and sisters? They seem to love you so much. I watch how you interact with them in session. You are so good with them.”
YP: (Becomes tearful)
The social worker knows that the young person has been very protective of them since their births. They jump into bed with her in the morning. She cares for them when mom is at work. And when mom is losing control, she offers them safety. This offers the opportunity for the young person to see that her younger siblings, who she adores, will be affected if she dies. She acknowledges that she has never thought about this.
Adolescents must come to see that their therapist “is not judging me, but trying to understand me and know that although I am in pain, I am willing to change.” This brief article offers practice illustrations and principles for helping young adolescents and their families, who are struggling with finding alternatives to suicidal behavior, to cope with painful life circumstances. In order for these approaches to be successful in saving lives, preventing hospitalization and preserving families, a strong system of children’s outpatient community-based mental health centers is essential.