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Self-Harming and Cutting, A Primer for Parents- Part 2

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Michael Reed, MA LMHC Family Counseling Associates of Andover

This post will address the topic of how to talk to adolescents and teenagers about suicide. In a previous post, I tried to create a primer of sorts for parents to understand self-harming behaviors, specifically cutting, and to give some context for how to approach the topic with their children. In this post, I will follow that same format by attempting to create an overview on the topic of suicide, how to understand these thoughts, and how to speak to your children about them while avoiding common pitfalls. My goal is to address popular misconceptions and to provide insight as to how to speak about such a difficult topic openly and directly.

A Parent’s Worst Fear

The topic of suicide is understandably a challenging one, but much more so from the perspective of a parent who fears that their child may be experiencing these kinds of thoughts. There is the fear of what the answer might be if you ask the question directly. There is the fear of not knowing how to respond if the answer is “yes.” There is the fear of wondering what could have led to this point or wondering whether you have missed signs in the past. There is often the belief that you should have and would have noticed if something were that wrong and the reticence to believe that your child and family could be affected. From countless conversations with parents throughout the years, I have heard all of these concerns voiced regularly.

The Spectrum of Suicidal Thoughts

What may be helpful first is to give some further details about the forms that suicidal thoughts take, as there is a broad spectrum and the answer is rarely as simple as a yes or no. When speaking to teenagers and adolescents, I explain that I see these thoughts as being part of a wide-ranging continuum, starting with more passive thoughts and becoming gradually more proactive and dangerous.

The most passive form of suicidal thoughts (or ideation, to borrow the common language within mental health circles), can be due to any number of factors that may feel overwhelming. This could include stress, bullying at school, or academic pressures. They may also be reflective of emerging mental health issues such as depression or anxiety. What passive ideation means is most often a wish that they had never been born or that they were dead. This type of thinking is quite common as many teenagers feel that external pressure or the weight of negative emotions are too great and they wish that the burden was taken off of them, that they no longer had to face their struggles. In this situation, they have no plans to harm or kill themselves, have never thought through what they would do and have no desire or intent to make any attempts at self-harm or suicide. There is nothing proactive about their thoughts, but there is a general feeling that being dead would be preferable to these negative feelings and pressures.

From that point on, the spectrum becomes increasingly more proactive, first crossing the threshold from passively being open to the idea of harm coming to them to beginning to consider the possibility of taking specific actions toward this end. The questions that we ask and consider in our assessments are used to gauge how far along this spectrum of action an individual is.

  1. First, have they given consideration to how they would hurt themselves? Is there a specific plan?
  2. Beyond that, the next step is whether or not they possess the means by which to carry out said plan.
  3. And lastly, if there is a plan in place and there exists the means to carry it out, then it becomes crucial to know whether or not there is a specific intent to follow through on this plan in the immediate future. If an individual has a specific plan in mind, the means to achieve that plan and the intent to enact it soon, that would be the most imminent and concerning, with that individual being in need of immediate help and support. This would likely involve a trip to the emergency room and a crisis mental health assessment.

Most individuals fall somewhere in the middle of this spectrum, with some being firmly in the
passive category and others having given some degree of thought to how they would make an attempt but never feeling that they would take it any further. This is why it is crucial to ask clarifying questions, to not shy away from asking for details. To know how best to help your child and the level of support they need in that moment is determined by these details.

Warning Signs

There is then the question of knowing what the warning signs look like. Oftentimes the signs that a teenager is struggling will be manifested in their day to day activities and through common symptoms of depression. This can often take the form of a decline in academic performance, isolating socially and no longer spending time with their friends, or no longer finding any pleasure or enjoyment in favorite activities. Other symptoms could be poor sleep or over-sleeping, general lack of motivation, etc. It’s also important to note that depression or anxiety in teenagers and adolescents can often be seen as a sharp increase in anger or volatile moods. This is a result of feeling exhausted emotionally, of feeling overwhelmed by the constant weight of negative emotions – they feel burned out and thus feel unable to manage even minor incidents.
There are of course more significant signs such as giving away prized possessions that they feel they have no further need of or of engaging in self-harming behaviors. It is important to know that there is no direct correlation between self-harm and suicidal thoughts; some who cut may never experience these types of thoughts and many who do experience suicidality have never engaged in self-harming behaviors. However, in some individuals, it can be reflective of more serious and concerning thoughts and its presence should never be ignored.

How to Speak to Your Child about Suicide

The question then becomes how to speak to your child about suicide. The most important thing is to ask. Even if you do not feel confident, even if you are frightened at the prospect, the key is asking. Asking clearly and directly. Do not equivocate or use euphemisms. Do not hedge or couch your language in uncertainty. Do not ask leading questions where the answer that you want to hear is implied. Clear communication is essential to ensure that you are both on the same page, that you both understand what the other is saying, and that honesty is encouraged. A common myth is that asking a person if they are feeling suicidal may, in fact, cultivate suicidal thoughts where there were not any prior. This is never the case. There is a reticence, often anxiety, and sometimes embarrassment on behalf of the individual experiencing these thoughts, but it is virtually always followed by a sense of relief that someone knows and is willing to ask. So ask directly, openly and confidently.

I have had numerous teenagers in the past who have opened up for the first time about their suicidal thoughts, anxious about sharing but glad that someone asked and that someone else now knows – that they do not have to face this alone. I have asked many of them what kept them from opening up to a therapist, a teacher or their parents in the past and have countless times been met with the response “Nobody ever asked me” or “I didn’t know how to start that conversation.” It is our job to help begin that discussion and create space for it.

It is also important to remain calm. It is entirely appropriate to let your children know that you are upset and you should not feel that you have to hide your feelings, but it is important to remain in emotional control. There is already a sense by those who are experiencing thoughts of suicide that something is very wrong with them. They know how concerning the problem is, but I have also heard countless times that they did not want to worry their parents. They didn’t want to cause a panic. When an adults asks questions and engages calmly, rationally and without panicking, it can be very normalizing, very grounding and create in them a sense of calm and trust. If they confide in an adult who then panics, it creates a further sense of panic in them, the feeling that they need to walk back what they said, minimize their feelings in an attempt to try to mollify the upset parent.

Be calm, let them know that you are sorry that they are experiencing these thoughts and validate how frightening it must be to feel that way. Let them know that you are concerned for them but that you are in this together, that you will work with them toward getting them the help they need. I had one 13 year old girl confide in me several years ago about her struggles with suicidal thoughts, which had progressed quite far along the spectrum toward taking action. When I asked her why she had never told this to her parents, she responded that she “knew that they would never be able to handle that” and that she “didn’t want to put that burden on them.” They need you to be calm and to help support them through this, even if you yourself are uncertain.

If your child does endorse these types of thoughts, stay calm, ask questions, and be specific and open. Do not hesitate to ask them how far their thinking has progressed along that spectrum. It is also important to make sure that you work out with them a plan for keeping them safe. This may include an increase in supervised time with them, cultivating a list of trusted people whom they can reach out to if they feel unsafe, checking in regularly throughout the day with them and having them give you an update as to their emotional status. It may also be helpful to come up with a code word that is private between you two but which, if said or texted, would be a signal that they are not okay and that they need immediate help.

Moving Forward

Work with them to get them the support they need, coordinate starting therapy, or if you do not feel that they are safe in that moment, never hesitate to take them to the emergency room or call 911. Many parents do not realize that emergency rooms are equipped to handle not just medical but also psychiatric emergencies and many employ full time therapists to be on-call for this type of situation 24 hours a day. I have spent countless hours in emergency rooms in the middle of the night with children and families, completing assessments and asking questions. A common fear is that trip to the emergency room means that they will be admitted to a psychiatric hospital, which is not the case. Many times they are sent home with family, a safety plan in place and a follow-up appointment for therapy scheduled. This fear should not be a deterrent to them getting help that they need or seeking emergency services.

The topic of suicide is among the most challenging that a family can face, both for the individual who is feeling overwhelmed and frightened of their emotions and for parents who want to protect and help their child. The key is to communicate calmly and clearly, to be specific, to be honest and open and to assure them that you are there for them, that there is nothing that they can say which will change that and above all, that you will work together to get them the help and support that they need. And this all starts by asking the question.