It’s so simple,” my client says. “Not just the lyrics. The melody too.”
I smile, agreeing with her assessment of Radiohead’s “True Love Waits.”
Olivia, a bright high school sophomore whose favorite thing to do is hang out with friends, loves music. In the four months we’ve been working together, we’ve often talked about bands we like or have just discovered. It’s been one of our touchstones as we work on treating her depression and increasing her involvement in activities that align with her goals and values, like volunteering at the local animal shelter and spending time with her loving family, who clearly has her back through her emotional ups and downs. A few weeks ago, she even started working with a psychiatrist. All signs have been pointing in the right direction.
“It’s so beautiful,” she continues, closing her eyes as if the song were playing in my office right now. “When I’m listening in my room, it’s like floating in the ocean.”
We talked earlier in the session about what she’d say to herself over the weekend if she felt like isolating in her room instead of hiking with her family: “Remember, you always feel better once you get out there, even when your brain tries to trick you into thinking it’ll be awful.” We discussed what she’d do if going to school on Monday morning filled her with dread: notice the urge to avoid and do the exact opposite. While hard to execute in the moment, this strategy has worked well for Olivia in the past, and her dread usually lifts once she gets to school.
As the session ends, I tell her I’ll definitely be listening to “True Love Waits.” She nods, stands up to leave, and then hesitates and sits back down. “I probably shouldn’t tell you this,” she says, her voice trailing off.
“What’s going on, Olivia?” I ask gently.
She takes a slow breath. “I just don’t think I can do this anymore,” she says. Her eyes fill with tears, and she buries her face in the sleeves of her sweatshirt.
“What do you mean?” I ask.
“I’m done with trying,” she whispers. “It’s too much.”
She stops crying and slumps in the chair. Her normally expressive face goes blank.
What’s she “done with,” exactly? Done with treatment? Done with her parents? Or does she mean she’s done with her life?
“Olivia, are you thinking about suicide?” I ask softly.
“Kinda,” she says, looking away. “I mean, sometimes I think about it.”
My body tightens. Even after years of treating suicidal teens, my nervous system responds to this kind of admission with a jolt. Easy banter is off the table now: the stakes are too high.
You may be well trained, versed in all the proper protocols, but the first few times a kid shares that they’ve been having thoughts of suicide, your hands will prickle with sweat and your heart pound so loudly in your ears it’ll be hard to think straight. Am I equipped to help? I used to wonder. What happens if I don’t do or say the right thing? Isn’t it safer to send them to the hospital right now, this minute?
I’d be lying if I said, these many years later, my response is one of unwavering calm. But most of the clients accepted into our comprehensive Dialectical Behavioral Therapy (DBT) program report suicidal ideation at intake, so I’ve come to accept it as a sign that a kid needs help. The teens we see experience intense emotions, which lead to risky behaviors like self-injury, and take actions intended to end their lives. I know a lot more now about what follows an admission of suicidal thinking than I did as a new clinician.
Also, the fact that DBT is a frontrunner in reducing suicide attempts, self-injury, and self-harm for this age group comforts me. Those of us who practice it are steeped in the causes of suicidality and techniques for addressing them in effective ways—which makes it easier to breathe through any rising panic and help the teen in front of me.
The problem is that these days, a lot more teens need this help than ever before.
What Are We Facing?
Suicide is currently the second most common cause of death among teenagers in the U.S. For every completed suicide, there are likely hundreds of suicide attempts, and exponentially more suicidal thoughts. The rate of teen suicide was on a decline through the early 2000s but has increased by about a third over the past decade. Nearly a quarter of high school students—and three in 10 high school girls—report seriously considering suicide in the last few years.
Those of us on the front lines of this trend often talk about the role played by social media. On the one hand, many teens feel it’s their primary source of connection with friends and the culture, a perception cemented during the pandemic. On the other hand, when that connection turns to criticism and bullying, many young clients also feel it’s a source of alienation, rejection, and suffering.
In DBT, we use a skill called “checking the facts” to help clients sort through whether painful emotions are prompted by actual events, or by their interpretation of events. When kids’ interpretations are heavily influenced by the voices of internet trolls bullying them or reinforcing their sense of peer alienation, they can make rash decisions, particularly when they can’t access the fully developed prefrontal cortex, which helps adults control impulses.
Another common thread that providers at our clinic believe may be contributing to increased suicidality relates to the fact that teens today are absorbing the message that feeling bad is in itself bad, rather than normal. In a culture that turns to medication to relieve all forms of pain, the willingness to tolerate the necessary pain that accompanies growth is diminishing. Teens in emotional crisis often look for immediate relief, and when it isn’t available—or when relief stops being effective—suicide can seem like a reasonable option for ending suffering.
For many young clients, DBT offers protocols to assess risk, harness support, problem-solve, and keep them socially connected in their communities so they can practice new skills and cope with the emotions that have led them to seek treatment in the first place. Learning affect regulation and interpersonal skills helps them reengage their prefrontal cortex during moments of high emotionality and impulsivity. But before teaching clients these skills, we often need to respond to admissions of active suicidality quickly and effectively—with a sense of curiosity and understanding, rather than sheer panic.
In the past, Olivia had reported some hopelessness and passive suicidal ideation—the occasional fleeting thought of being dead without a plan or timeframe—but she hadn’t revealed any active suicidality during our sessions, nor during the initial questions about suicidal ideation at intake that are part of the Mental Status Exam. I’d added her passive suicidal ideation as a treatment target, hoping that once she’d reduced her stress, taken breaks, and communicated her needs to her support network when she was feeling overwhelmed, her brain wouldn’t need to feed her these thoughts about escaping life.
But today’s admission feels different. Her face had been expressionless, and there was a heaviness to the way she’d said kinda to the question of ending her life. It was enough to tell me that I needed more information—which would take time. Luckily, Olivia is my last client of the day. I’ll be late to dinner, but when an emergency like this arises at work, my family always understands.
Assessing and Connecting
Suicidality is frightening, but rather than becoming alarmed and immediately referring a teen out to emergency care, therapists have options that can keep many teens safe and out of overwhelmed ERs or locked wards, where they may experience ineffective care, or possibly no treatment at all, while waiting days for an available bed. Over the years, and especially recently, my colleagues and I have found that connecting, assessing, and treating clients within their familiar communities are usually a better option than sending them to an unfamiliar ER.
To manage my own emotions and think clearly about these options during Olivia’s suicide risk assessment, I start with self-validation. It makes sense that you’re feeling increased emotional intensity, I tell myself. No matter how many suicide plans you’ve heard or how many clients have disclosed suicidal thoughts, it’s always heavy. But you’ve got this. You’re here to serve Olivia. You have the skills and experience to do this. It’s positive that she trusts you enough to share.
Next, I tune into my body, bringing awareness to any tension in my neck, shoulders, and back. This internal check helps me acknowledge my own emotions, so I can model for Olivia how to stay regulated and skillfully navigate tough situations. In many ways, I tell myself, connecting with her now isn’t different from doing so at the less heightened emotional moments we’ve already shared.
Of course, I don’t want to communicate to Olivia that planning to kill oneself is an everyday experience, but I also don’t want her to think there’s something so wrong or crazy about what she’s disclosed that she should feel guilty or ashamed. Inadvertently punishing her for revealing thoughts could affect her willingness to share suicidal ideation or a plan in the future.
I tackle her disclosure one step at a time, sitting upright with my hands resting gently in my lap. This soothes my own nervous system and communicates a willingness to take in whatever she has to say. I intentionally adopt a gentle smile and relax the muscles around my eyes and mouth. And I lean in to offer closeness and connection.
“Thank you for telling me all this,” I say in a warm, calm voice. “I see things feel really tough right now. Since this is the first time you’ve mentioned you might want to end your life, we’ll need to conduct a suicide assessment.”
Risk and Protocol
Olivia frowns at the sight of the seven-page document I pull from my file cabinet. Like most suicide risk assessments, the Linehan Risk Assessment & Management Protocol (available free online), asks about plan and means, and considers other factors related to the person’s environment, home life, school, and community. It guides me from risk and protective factors to recommendations that remind me to check in with a team member, bring in support, and schedule follow-ups.
“Don’t worry,” I reassure Olivia. “Most of this is just for me. I only need you to answer a few questions. Like always, we’re having a conversation.”
I make sure my shoulders are relaxed before asking the first question: “Have you thought about how you would end your life?”
She pauses, uncrosses and jostles her legs, then says, “Wait, are you going to tell my parents?”
This question inevitably comes up with adolescents, and not just those who disclose suicidality. It’s why we go over confidentiality when first meeting them with their parents, and then again at various points throughout treatment—like when they’re nearing a disclosure that may require us to break confidentiality, or when they have disclosed something we need to share.
I give reminders often so young people don’t feel surprised or betrayed if I do need to bring in parents out of obligation to my ethical code, concern for their safety, or because I’m hoping to increase support for them between sessions—which is the case with Olivia. My gut tells me I’ll be bringing her mom in after our assessment.
“Right now, it’s you and me, here together,” I explain. “My top priority is figuring out how to best support you. I’m not sure yet where this will all lead, and I care about you too much to make false promises. You’ve demonstrated so much courage already.” I pause and ask, “Can we jump in together and see where we go next?”
“I guess so,” she says tentatively.
As we go through the assessment, Olivia reveals that she does, in fact, have a plan to take the remaining 10 SSRI pills in her prescription, and swallow them with Drano left over from her dad unclogging the shower recently. This, she believes, will end her life. She admits that the SSRIs, which she began taking three weeks ago, haven’t brought her much relief.
“I’m stressed out at school,” she adds. “My best friend I told you about, Celine—she won’t speak to me because of an Instagram picture I took when we had a sleepover. She says I made her look bad on purpose. I told her I was sorry and deleted the picture, but she still won’t unblock me or sit with me at lunch, and now some older kids are bullying me online, probably because of her. It feels like I’m this loser with no friends who’s under attack every day, and like my whole school sees what’s happening but no one stands up for me.”
Once she’s gotten this out, I notice she seems less fidgety. I thank her for sharing and move on from risk factors to protective factors: her reasons to live. We explore meaningful relationships (including ours), religious beliefs, social support, hope for the future, and negative beliefs about suicide. During this process, I discover she’s scared of death and of leaving or hurting her loved ones.
“My cat Muffin sleeps in my bed every night. I’m scared she’ll be lonely and depressed without me petting her.” As she talks, she grows animated. “Also, what’s going to happen to my brother? He’ll be in high school in a few years. Boys are going to bully him. It’ll be harder for him without my help.” Her love for her cat and brother are palpable. This is good news: absence of emotion is a risk factor for suicide, but the return of emotion, even tender emotion, is protective.
Weighing the balance of risk factors versus protective factors is a key part of suicide assessment. Her protective factors are compelling: she doesn’t want to hurt her family; and knows killing herself would cause them tremendous pain. Although I want Olivia to have intrinsic reasons to live, that’s long-term work. Right now, I need to know she can manage her distress in the short term.
“I do want some help,” Olivia tells me. “I just feel so stuck, and it seems like all of this has been going on for so long. People are shitty, and I know that’s not going to change.”
I promise her we’ll get to problem solving and that things absolutely can change for the better. But for the moment, I tell her, what’s most critical is keeping her alive, so we can do the work of improving her life and relationships.
“Thank you, Olivia, for sharing all of this,” I say once we’ve completed the assessment. “That took bravery. I can’t imagine what it’s been like to carry all this by yourself. It sounds so heavy.”
Though she’s slumped in the chair, her face appears less pained. A glimmer of nervous expectation flickers across her face as she exhales and asks, “Are you going to send me to the hospital?”
“Do you think you need to go to the hospital?” I ask.
“I was scared to tell you,” she says, tearing up. “Every time I start to get control over something, another bad thing happens. I want to make it all better, but I don’t know what to do.”
“Thankfully, we seem to be on the same page about what not to do.”
She meets my gaze.
“See, the good news is, I know what to do. I have a lot of ideas about how we can ‘make it better,’ but I need one thing from you. I need you to commit to staying alive so we can get this sorted out. Can you do that?” I ask.
When I started working with suicidal clients, I wouldn’t use this kind of casual, irreverent tone. As a seasoned clinician, I sometimes use irreverence and ask for a direct commitment from clients to abruptly shift cognitions, emotions, or behaviors. While it may seem that I’m making light of something serious, a casual tone can have a powerful effect. With Olivia, I was looking to highlight the seriousness of what we were discussing, reinforce that I’m in this with her, and make it clear that there’s a path forward, if she does her part, too.
Now I ask her, “Can you tell me if you know what ‘making it better’ might be for you?”
She offers a tiny grin, and says, “I think so.”
This is a wonderful start, I think.
Why Not Hospitalize?
Suicide often comes up for teens when their problems seem to be unresponsive to attempts to solve them, or when the skills they need are underdeveloped or inaccessible. Still, when suicidal ideation is expressed, therapists often have a predictable knee-jerk reaction: hospitalize. Hospitalization is a viable option, but we should recognize that people rarely want to kill themselves when there’s another way to solve a problem.
Although Olivia’s plan to ingest 10 SSRI pills with Drano is unlikely to result in a completed suicide, it still has me worried. This is where Olivia’s mom will play a critical role. At the end of the session, I’ll ask her to join us. We’ll discuss how she can help lower the risks inherent in this situation and strengthen Olivia’s safety plan. The first step when they get home will be to lock up or dispose of medications and chemicals.
Olivia’s rift with her best friend flooded her with painful emotions on top of strong vulnerability factors, including her depression. At the same time, she wants help and has a lot to live for, including her cat and brother. If I can generate hope, activate support in her environment, and get her to our next session, I don’t think hospitalization is necessary. In fact, being hospitalized will make it harder for her to speak with her best friend and work through their conflict. It’ll exacerbate her stress as schoolwork piles up. She’ll lose access to me, and our treatment will be put on hold.
Although a hospital would provide supervision, medication management, and generic group options, it wouldn’t offer much support beyond stabilization. Plus, with so many teens in crisis, there may not be a bed available locally—which might lead Olivia to a distant hospital, hours from her beloved cat and family. Locked wards are a far cry from a peaceful respite. Clients of mine have been physically and sexually assaulted by other patients, self-injured, and witnessed serious self-injury and suicide attempts. This may be rare, and hospitals do the best they can, but I prefer to avoid exposing clients to this risk if possible. Indeed, though a hospital may feel like a safe resource, there’s no evidence that being in a hospital prevents suicide after hospitalization. Suicides occur in hospitals too.
By doing suicide risk assessments in our offices, we can bypass the risks that come with acute hospitalization. Often, our clients can get community-based help through outpatient services they’re already connected to, ones that personalize treatments. For Olivia, this might mean further medication trials with her psychiatrist and being considered for our comprehensive DBT program. We could add a DBT skills training group to her treatment plan, offer her phone coaching between sessions, provide support to her parents, and continue to build psychological skills in therapy.
Through the DBT lens, the situation with her best friend is an opportunity to teach her interpersonal skills like self-respect and self-advocacy, observing and describing a situation nonjudgmentally, and taking a step toward conflict resolution by thinking dialectically and seeing all sides and perspectives in a charged situation. I can teach her skills to reduce impulsivity, problem-solve when she’s faced with stressors, and prioritize when too many tasks become overwhelming.
Doing this in an outpatient setting means inviting her family to play a more active role in her wellness, starting with the basics of good health. Is she eating nutritious meals, sleeping enough, and exercising? Is she treating herself with kindness? Are her medications helping? What dangerous household items need to be locked up while she’s particularly vulnerable? Her mom might benefit from resources, like a parent support group or parent therapy in our program. Olivia’s healing, with a strong scaffolding of safety in place, can unfold alongside people who love and care about her.
Of course, emergency services are sometimes necessary. It helps to ask, Am I referring my client to the hospital because suicidal ideation is scary to talk about and treat, or because it’s truly in their best interest? If Olivia had shared a more immediate and lethal plan, refused to commit to a clear safety plan, or to include her mom in our conversation, then, yes, I may have sent her to a hospital.
I once had a young client who’d attempted suicide the day before our intake and wouldn’t commit to not acting on suicidal plans again, swearing he “wouldn’t mess it up next time.” I didn’t know him well enough to trust that the assessment, commitment, support gathering, and treatment planning process could keep him safe. Eventually, he agreed to bring in his mother and go to the hospital, but if that hadn’t happened, I’d have created an emergency petition to commit him involuntarily.
Telling the Parents
“Olivia, let’s talk about how to bring your mom up to speed,” I say.
“Do you have to tell her?” she pleads. “She’s going to be so upset.”
Orienting teens to what we’re going to tell parents when we need to override confidentially is important. Though Olivia doesn’t like that I have to do this, our relationship may be strengthened by the compassionate way I communicate the situation to her mother and align with her to increase safety.
“Do you remember that this is one of the exceptions to confidentiality we discussed at the beginning of treatment?” I ask. “You and I will tell her together, okay? Support from your mom can help us make sure you stay safe this week.”
As I stand up to invite Olivia’s mom into the room, Olivia smiles weakly. I pause at the door and say, “I’m proud of you. That was hard, but now we can start the real work. You may not believe me right now, but things won’t always feel this difficult. If taking it one day at a time seems too overwhelming, break it down, okay? Take it moment by moment. You can do this. We can do this together. Got it?”
“Got it,” she says. Her voice is quiet, but her answer is firm.
When Olivia’s mom joins us and sits down, I explain I’m proud of Olivia for sharing her sense of anguish and hopelessness with me. Then, I tell her that her daughter is having thoughts of suicide. As her mother tears up and reaches out to hold Olivia’s hand, I emphasize we’re going to work together to keep Olivia safe. I share Olivia’s plan to take the pills and Drano. “It’s important to lock up all medications in the home as well as any caustic chemicals,” I advise her. I know Olivia could easily walk to the local drugstore for these items, but I also know suicidal thinking is fueled by emotionality and impulsivity. If I can put time between the urges and the means, highlight her reasons to live, teach skills for managing emotional dysregulation, and get to work on solving her problems, this moment of increased risk will pass.
By the time Olivia and her mom leave, all three of us are clear about the supervision plan and the steps we’ll take to keep Olivia safe till her next visit. I put the assessment back in its folder, turn off the lights, and walk through my empty office. Outside, dusk has fallen. As I get in my car, I pause, going over a mental checklist one last time to assure myself that we did what we needed to for now. Then, eager to see my own family, I set off for home.
As therapists, we find ourselves in an extraordinary position. Clients who share their suicidal thinking are often begging us for a way out of their pain that doesn’t involve ending their life, and they’re giving us a chance to intervene as caring and well-resourced professionals. It remains to be seen whether the increase in teen suicidality we’ve witnessed over the past decade will eventually abate. For now, we must remain grounded and seek out training and support to guide kids out of the suffering that overwhelms them, one client at a time.
Illustration © Ole Schwander
Samantha Ascanio, LCSW-C, is director of the Linehan Board Certified Dialectical Behavior Therapy Program at Capital Youth Services.
Britt Rathbone, LCSW-C, ACSW, BCD, CGP, provides mental health services to adolescents and their families in the Washington, DC metropolitan area. He has 30 years of experience working directly with adolescents and families, is a “top therapist” for adolescents, teaches graduate students, trains therapists and leads a highly regarded and successful clinical practice. He lectures often on the value of DBT with young people. He is a dynamic and passionate speaker and his trainings consistently receive the highest ratings. He is the co-author of Dialectical Behavior Therapy for At-Risk Adolescents, What Works With Teens: A Professional’s Guide to Engaging Authentically with Adolescents to Achieve Lasting Change, and Parenting a Teen Who Has Intense Emotions (to be published by New Harbinger in January 2016).