Strategies For Addressing Youth Suicide—And The Barriers to Effective Treatment

King

Cheryl King, PhD
Institute for Human Adjustment, University of Michigan
National Network of Depression Centers

Suicide is the third-leading cause of death among 15-to-24-year olds, and youth suicide remains a challenging public health problem that is strongly linked with psychiatric disorders and other mental health issues.

Research shows that there are effective education, prevention, and treatment intervention strategies to address this problem. However, there are also barriers that prevent young people from receiving the kind of help that can make a difference.

Some Evidence for Effective Approaches
While it’s a challenge to gather evidence for strategies that address suicide prevention, research indicates that certain approaches lead to increased awareness of risk factors, more referrals to treatment for those at risk, and reduced suicidal thoughts. In some instances, the studies have been large enough to look at reduction in suicide attempts. But we can’t say we have data on treatments and interventions that are actually shown to reduce suicides in youth.

Targeting the Suicide Risk
One thing we’ve learned about psychotherapy and treatment that targets acutely suicidal young people is that it’s important to target the suicide risk directly. While it’s helpful to treat the primary risk factors—the depressive or bipolar disorder, substance abuse issue, or anxiety problem—our evidence suggests that to have an impact, we need to address the suicide risk itself.

We look at each youth’s constellation of risk factors—and there is very clear evidence on risk factors—and then target these risks, but also seek to understand why a particular youth is considering suicide or having suicidal impulses, when many with the same risk factors are not.

Evidence tells us that aspects of cognitive-behavioral therapy and dialectic-behavioral therapy that focus specifically on the patient’s self-harmful and suicidal thoughts and behaviors can be effective. As an example, cognitive-behavioral approaches may include addressing hopelessness through creating a Hope Box, which is a literal or figurative collection of things or ideas that have meaning to the young person, and that they consider important for their future; and targeting relapse prevention by identifying a patient’s  “downward spiral” or behavior/thought pattern that preceded past suicide attempts, and intervening before it results in another attempt.

These treatments also include working with a therapist to create a “safety plan” that includes

  • personal triggers for self-harmful and suicidal thoughts
  • coping strategies
  • means removal
  • reasons for living
  • emergency contact names and numbers.

Barriers to Effective Treatment
While evidence supports the use of these interventions, there are significant barriers to treatment for the youth who need it.

A basic barrier is lack of recognition of the problem or risk, either by the teen, their family, or those who interact with them regularly. Teens may be

  • unaware that their problems are treatable
  • concerned about the stigma
  • put off by the idea of needing help.

The people around them also may not recognize a young person’s problem as a treatable mental disorder. Some of our more universal strategies—awareness campaigns, school workshops, parent events that educate about warning signs—can help get at these barriers.

Even once a problem is recognized, good help—meaning proven treatment or intervention strategies—is not always available for young people. Well-trained clinicians may not be available in the community, and families don’t always recognize whether their provider has the right skills to address the youth’s particular problems.

Educating consumers is one way to go, but we find that in this and all areas of healthcare, it’s difficult to be a vulnerable or struggling patient and be highly assertive about your treatment. An essential component of an effective solution will be to build a more competent and caring clinical workforce, ensuring that clinicians are trained in how to conduct a suicide risk formulation, implement best practice treatments, and conduct ongoing risk assessment.

Financial resources can be another hurdle. In the United States, personal funds often buy better care. Access to quality mental health care depends upon the type of insurance coverage. Often there is a direct correlation between out-of-pocket costs for plan coverage and limits placed on treatment options. Many battles remain to get adequate coverage for everyone.

While barriers exist for everyone, they’re especially challenging for those with severely limited financial resources. Our public mental health system has been facing reduced funding, and although there are excellent providers in this system, they are not in every community. Waiting lists can be long, to the point where an acutely suicidal teen discharged from a psychiatric hospital can’t get an appointment with a clinician within as week, as would be recommended. Unfortunately, the patient simply might not be perceived as being most in need for an appointment in the public mental health system.

The Audience’s Turn:

  • What barriers have you met in trying to get psychiatric help for a teenager? How did you overcome or work around them?
  • What have your schools or community done to prevent youth suicide? In what ways do you think this is effective, or not?

Dr. King’s upcoming post addresses public policy challenges and priorities related to youth suicide prevention.


What do you think should be highest priority in addressing youth suicide?

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13 comments
StephenBonin
StephenBonin

Goodmorning! I'm going to share a few thoughts, then go to the bottom--the first post of the week--to start responding.


1. I will be getting my own lap top very soon, perhaps today; thus, I plan to do better with occasional issues of lack of clarity. Specifically, in the introduction yesterday, I reported that my younger brother was bullied. He developed depression and lashed out to me: "I HATE you." That's why I was compelled to beg his forgiveness upon being enlightened in August or September--so many years later.

2. Aware that I offer a lot of personal information, I do so with the hope that you are thinking about the problem as a whole. In mentioning the idolatry of football, I see many men hired coaches in the schools. I see male principals and entire schools acting in tradition with Pep Rallies, Game Night, and media coverage. The male players are made to be idols. Males in band typically not so. Even though I said I live in a small city, the daily newspaper's mentality is of small town. Plus, there is a cluster of very small towns around us. I am opposed to the newspaper's publication every late summer of a Fall Football Preview, in which all county schools players head and shoulder shots are big, and the bands do not receive equal treatment! In fact, ALL the band members are pictured in a tiny frame! With my arts advocacy knowledge, I want to produce a letter that our DBSA co-officers would work with me on, regarding the wisdom of acknowledging students in the arts equally footing.

3. We were asked this week schools or community have done. I wrote a response, and thought of more to say. The ROTC group from our city's high school floats around the 1/2 gymnasium (actually a church Family Life Center) on Mondays during the 2 1/2 hour Free Lunch. Attendees are singularly or in combination materially, spiritually, mentally, emotionally lacking. This church's servers joyously own their ministry; in other words, it's not just serving a free meal once a week. The ROTC students proudly and lovingly ask guests if they can throw away their empty plates, get them more drink, etc.

4. Thinking about this and my fulfilling time at the nursing home, an idea seems so good. Activity Directors could go to middle, high schools, and colleges, to churches as well, to recruit volunteers. They could promote the wisdom that not much effort at all, just a beautiful smile, lively eye contact, and shoulder hugs or more benefit both the volunteer and the residents.

StephenBonin
StephenBonin

Now, question #2. This question gives me the opportunity to share some information that could have been posted earlier. In our community a private organization funded by trusts and grants, VOICE--Viable Options in Community Endeavors--employs people skilled in teacher qualities to make presentations in area schools. Their subjects run the gamut of lowering risks for youth suicide, including "Saying No to Drugs," "Managing Anger," "Being Respectful, Civil and Kind; Not Bullying," "How to Have Healthy Self Esteem/ Confidence," etc.

Another example is generated from an assistant principal of a middle school here. Every morning on the intercom, the principal commends groups of students, such as "Mrs. Brown's Fifth Period," or "Mr. Jackson's Percussion Section in the Band." The assistant principal told me that encouraging acts of kindness and civility is born out of Rachel's Challenge, the project that developed after the girl was shot dead in Colorado.

Also, referring back to the presentations of VOICE, I have learned that church youth ministry weekly programs, such as my own, do the same good. Eddie Ruesewald, our Youth Director, also shared, "Every week we meet for a serious topic, prayer, food/drink, socializing and fun, we always look out for youth who are isolating.

My colleagues, I will respond to your thoughts Friday evening through Sunday. Thank you.

StephenBonin
StephenBonin

Hi colleagues. The weather is beautiful in central Texas right now. We've had plenty of rain to help gardens. However, we still need more for our huge lake that people fish in and boat on. In other news, before answering the questions, I'm going through some important transitions. I am grateful for this unit on preventing youth suicide because it has sobered me. My mood deflated this week (receiving affirmations in this project swelled my ego), so I was forced to examine, "What more can I do so that I'm not relying on too little?" I had to answer that two ways. First, for myself. I have not played my guitar in a long time, nor have I spent time with folks in nursing homes. The guitar playing every day will restart soon after the strings get changed. Today I went back to a nursing home and realized that doing a musical and conversational program with lots of spontaneity helps me tremendously--and them. Also, it ties into mental health advocacy because I deliberately lift my mood for people who are known to experience sadness/loneliness/depression.  A little ditty you may know goes: "Make new friends, but keep the old. One is silver, but the other gold." My guitar and nursing home involvement are types of friends, are gifts that I need back on a regular basis. Ii will bring my guitar (it is in a traveling case) to Washington, D.C. so as to fortify myself--form of prayer, like jogging to someone else.

Now as to the first question about barriers, I feel sad because a14-year-old living in the very small town nearby committed suicide last week. As was told by a member of our DBSA group who lives in that town, he was obese all his life and bullied. He had stated something to the effect that blood will spill in three days, for which the principal expelled him. Our DBSA member said, the principal did not probe deep enough that the youth was talking about his own.

The youth had been bullied his whole life. My family was in a small Texas town during my youth; we actually moved around, and wound up in Glen Rose because my Dad was named Assistant Plant Manager of the Commanche Peak Nuclear Power Plant.  After three years, he was transferred to the Houston office; my parents could not sell a wonderful four-bedroom home on ten acres, so he stayed in  an apartment there during the week for my brother Paul's freshman and sophomore years. Paul was a bit overweight, and was bullied by "macho" guys. Several months ago I got in touch with the fact that I did not defend Paul one time and called to beg his forgiveness.

All this detail serves a point. Paul emitted an insecurity because my Dad did not know how to communicate as a father. He was experiencing depression; however, he was exercising what he thought best--to stay with his worldwide company so as to be able to put four sons through college. Therefore, I'm addressing two issues here. One is the barrier of the type of parent my Dad was--basically civil, noble, however, not tuned in strongly to create an assurance in his non-football-playing son Paul. Secondly, the matter of football itself. I cringe at the iconic place Texas school football and players hold, and what goes along with it--nefarious, superficial, inflated egos such as my own before this week.

My plan is to draft a letter from our DBSA group--perhaps to newspapers in that town and ours, perhaps to the school, perhaps both, reminding people about our DBSA groups function, and the risk factors for youth suicide, including the bullied and those bullying.

Will answer question #2 next.

kimgallen
kimgallen

As a past swim coach, I have seen issues in terms of teens that appeared fairly clearly defined in terms of being isolated from peers, disinterested in school or social activities, and/ or demonstrated a sudden decrease in performance related to school, work, or sports. Though it was very tough, there have been times that I stated to parents that a psychological evaluation may be necessary. Though I did not have specific education regarding suicide at that time, I did feel that teens are at increased risk for depression and potential suicide due to pressures and conflicts that may arise within families, schools or social organizations, as well as intimate relationships. In addition, I met a fair number of teens that appeared to have a prolonged dependency on their families, and they appeared rather "stuck" in that phase. Several times I felt that those teens were not equipped to move into adulthood, versus the opinion of some other adults who felt that those teens were just low energy or not mature. As a coach, and ultimately as a licensed chemical dependency counselor, I opted to nurture those teens by holding conversations with them as individuals, stating to them that this crisis time would be resolved if they accepted help. This seemed to go a long way with them, though the stagnation they felt was a very significant conflict. Still, I encouraged them to know that they could still be successful. To me, developing this basic sense of trust with them was very important. Ultimately, I opted to coach younger ages also each summer, as I felt it vital to nurture children in elementary and middle school years, as well as in adolescence. 


Overall, as a coach and role model, I did what I could to help teens as they faced conflict. I felt it very important to help them plan for the future in the ways that I could. I formed appropriately close relationships with them, and helped them feel a stronger sense of identity as athletes, teammates and community members. Still, when psychological evaluations or psychiatric appointments were necessary, barriers did exhibit themselves. Some of that included getting other adults to also take prompt action in terms of having open and frank dialogues with those teens, particularly as it related to the possibility of suicide. 


As a present licensed chemical dependency counselor, researching which clinicians to call for teens took time and effort. At present, I know one excellent psychologist who works with teens, yet access is hard to come by due to long waiting lists. That being said, I know people in the mental health niche in larger towns who have been able to help with access, though families typically have to travel to those larger cities to get their teen's needs met. 

StacyK
StacyK

One of the barriers our family experienced in getting help for our loved one pertains to clinician training. Our loved once stated to her clinician that she was hurting herself and that she was experiencing suicidal ideations. The clinician told our loved one to try writing about her feelings. I don't want to say anything negative about a clinician because I've met some outstanding and credible clinicians. However, based on our experience, our loved one felt invalidated and like maybe she didn't have a problem due to a possibly inexperienced clinician. This happened a second time. After that she felt discouraged to open up and talk. It's like there is a negative ripple effect for families who have a loved one who lives with mental illness. For example, it made it difficult for us as parents to encourage our daughter to talk to a professional. Sadly, she went on to attempt suicide twice. I am glad to see that Dr. King addressed this type of barrier.

I may muddy the waters, but I think it's important to bring up another barrier our family experienced and that I don't think has been touched on here. When our loved one was unstable in the past we as parents had very few options to get her the help she needed. We were told to call for help if she was a harm to herself or others. That's tricky, especially once she legally became an adult. Once a child turns legal age it seems to be a matter of he said - she said. How could we as parents call for help when our loved one could simply dispute our concerns. Yet another concern with the protocol to call if a loved one is a harm to self or others is that it touches profoundly on a persons rights including the right to harm one self. I don't know what the answers are, but what we've found helpful is open communication with our loved one about our concerns and a discussion pertaining to how we most likely will react should a situation arise again. Based on our experience support is key as well. Our loved one knows that should a situation arise she can count on us to be there for her, and she knows that at the very least we will do all we can to support her and get her the care needed. I think support is vital to all persons involved. I wonder what other barriers might exist? Thank you Dr. King for talking about the barriers to effective care. Maybe if we can unearth the barriers we can develop solutions to overcoming them.

In the Burbs
In the Burbs

Dr. King, thank you for mentioning financial resources as a potential hurdle.  Our family deductible is quite high and our co-payment per visit has also risen.  Out-of-pocket expenses have grown considerably these past few years.  While we are not skimping on our child's psychologist visits, we have discussed  the frequency of appointments with her (I need to take time off from work for each appointment) and worked diligently to foster better communication between psychologist and primary care doctor (who prescribes medication and though much beloved, is yet another co-payment).  Stretching the health dollar is getting harder these days.  In our family's case, it took a bit before we overcame the stigma of being cash strapped before sharing our financial concerns with our health team.  However, we found a sympathetic and understanding health team who have done their utmost to help us get the most therapy for our dollars.

Craig_P
Craig_P

Thank you for sharing this comprehensive analysis. Another barrier is our country's deep history of independence and focus on success.

To "be strong" and succeed like a Rocky movie, and succeed 100% of the time, reinforces the stigma that it's ok and normal to need help too. Also, it is deeply woven into our country's fabric to turn down help. Youth learn all this at an early age. While exercising independence as a youth is supposed to be a lessor degree than an adult, there is NO question that youth are encouraged to emotionally and mentally "grow up" faster and faster regardless if they are cognitively ready for that level of independence. As youth "grow up faster" they, in fact, are not. They just dress and appear to act older than they are.

In my opinion, this undue stress that faces modern youth to live up to media and peer pressures can be beyond what they are cognitively ready for. I realize every generation goes through this, but youth are the #1 focus group of the Media. Therefore, our independent and success-oriented culture is affecting youth at a younger and younger age.

Limiting media like certain TV/cable shows is part of the solution. More parents need to know their kid's parents too. The more parents talk and are involved the better... (As long as the parent doesn't overreact that is!)

StephenBonin
StephenBonin

@kimgallen Very soon upon diving into Kim's narrative of her specific approach as a coach and role model, I felt energized! I could see and hear her making direct eye contact, smiling to the other person, and using her voice tone/words to make a hope-inducing impact! An automatic thought was to copy some of Kim's sentences into my response; however, that's not necessary because we can all read it ourselves in her post and know her in action! As I have been responding today to all, starting with Craig, I find the commonality of communication. I credit this unit for causing me to open my eyes wider, nod my head more, smile, and give more active listening cues to each individual whom I have opportunity to communicate with. It starts one to one.


Finally, Kim's encouragement to youth that the "crisis time would be resolved" (See. . .I did finally quote directly!) helped me remember once again my special mother, whose voice I hear in my memory from the first decade of the new millennium: "You WILL get through this."


Thank you.

StephenBonin
StephenBonin

@StacyK Reading Stacy's narrative of two barriers experienced between loving, concerned parents and their suffering adult child prompts awareness of my parents and me, during my ages 40 to 52. So grateful am I that I made it through a most difficult 12 years, in which I was levying harsh anger toward them. They did not deserve it because they did the best they could, sacrificing so much. As a Christian believing true justice is only with God, I can look no longer with negativity at my three-plus years with a "Best Doctor in Dallas" psychiatrist/psychologist, who the whole session wrote, but never in the next session would start off with, "Reflecting on my notes of last time. . ." I was locked up because of long-ago trauma when with him; therefore, I did not have the gumption to challenge him. Subsequently, I am grateful to be alive, and to be thriving. I mourn those who have lost their lives to suicide, yet I am responsible to greet every day with courage and hope, ready to help others experience some joy and peace.

StephenBonin
StephenBonin

@In the Burbs Kudos to you for breaking though the barrier of STIGMA! I have learned that being honest and transparent with the right people produces peace and, likely a solution we hadn't thought of. I feel happy to know that your parent and child communication is dynamic--reminds me of a song sung by a church choir in Mexico: "Comunicacion es Amor." Yes, communication approached in a careful, civil, well-thought-out and empathetic manner is of the essence. Regarding money matters, all we need to do is take optimal care of ourselves, dedicate ourselves to vast knowledge of resources, and have faith. Answers will appear. Thank you, In the Burbs, for the opportunity to reflect on key points toward hope.

StacyK
StacyK

Thank you In the Burbs for your insight! I'm so glad you shared you experience in regard to financial barriers and medical care. I think that you hit on what is so important and that is "talking!" Your openness to communicate with your care providers is such a great example of the importance of talking. I have learned as well that simply talking about our situation, pertaining to what we might need, can go far. In my experience, I also can learn a lot about a particular healthcare provider just by the feedback I receive once I've opened up and talked. If my concerns are not addressed I usually seek help somewhere else. Thanks again!

StephenBonin
StephenBonin

@Craig_P I agree with you, man. Morality in Media is a wonderful organization that can be found on the web. Craig, your focus on parents' relationships with their sons and daughters and parents' relationships with other parents emphasize the salience of slowing down this chaotic race culture practices. Yes, man, parents need to know that as they shift their priorities from being professionals and parents to being parents FIRST, that their relationships with their young will improve. Then, the overall health and altruism of youth will improve. I just read the book _Courage_, based on the movie, from the same company that gave us _Fireproof_. The principles you address are addressed in the book, with a Christian element.

StacyK
StacyK

Craig, it's nice to see you again! I'm glad you highlighted additional barriers. It's interesting because our country's very value system, especially in regard to independence sure does seems to be at the root of the problem like you mentioned. I wonder what solutions we could come up with in regard to overcoming the barriers, if we looked more closely at what other countries are doing. I still believe in our countries value system, but wouldn't it be great if we could integrate other ideas in an effort to erase the stigma? Your comments fuel my interest in learning more about what other parts of the world are doing!