Evidence-based approaches to working with suicidal young people

Article in Review: Sisler, S., Schapiro, N., Nakaishi, M. & Steinbuchel, P. (2020) Suicide assessment and treatment in pediatric primary care settings. Journal of Child and Adolescent Psychiatry, DOI: 10.1111/jcap.12282

Summary: The research by Sisler and colleagues (2020) considers the challenges in understanding young people’s needs and the workforce capacity to provide appropriate responses, in the context of suicidality. One of the key recommendations – which resonates well with the majority of clinicians is the need for compassionate and empathic responses.

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While there is always room for more research to help us understand the complex factors that contribute to suicide and suicide attempts by young people, there is a growing body of research that confers on certain screening, assessment, and treatment practices for suicidal young people. A recent paper has reviewed this research to identify best practice models to support primary care providers and nurses. The paper outlines tips for developing a patient-focused approach to work with adolescents who have been identified or assessed as having suicidal thinking or behaviors.

Developmental capacity of young people
When supporting young people who are suicidal, developmental factors such as the inability to process and cope with stress, a lack of fully developed impulse control as well as a lessened capacity for abstract thought should be taken into account. The impact of puberty has also been shown to play a significant role and it is helpful for care providers to have an understanding of a patient’s stage of development.

Approach
Maintaining the safety and wellbeing of the young person is the focus of any approach.  Establishing a good relationship with a patient is critical, and will allow for the development of a healthy therapeutic bond. Interactions with patients should be clear and direct. Questions should be posted in a way that is genuine and empathetic. As a practitioner, it is important to be aware of one’s own body language and emotions and to handle difficult feelings that might arise during the provision of support.

Examinations and determining risk severity
A physical examination will often need to accompany a psychological one. This may include looking for evidence of self-harm and injury, as well as evidence of possible substance ingestion. To determine risk severity, it is necessary to assess if there is suicidal ideation. This can be identified through a discussion around the intended method, and how imminent the intent is. The level of risk is also related to conditions related to the family, home, and school environment. Determining risk is also related to detailing supports and diversions in a safety plan. In cases where a patient exhibitions no suicidal thinking and behavior, risk should be listed as “minimal” and never “none”.

Safety planning
The creation of a safety plan, for patients to keep handy and readily accessible is highly recommended. A safety plan involves documenting:

• Any warning signs that suicidal ideation is increasing
• What coping strategies the patient has used previously or is willing to use
• People and social settings that might provide a distraction to the patient
• A list of people to contact for help, and their contact numbers
• Professional support people and agencies, and their contact number
• A list of protective measures to be taken around the home

When considering hospitalisation
There are mixed views about whether to admit a suicidal young person to a psychiatric hospital. Of course, such a decision will be dependent on the specific situation, as well as the presence of criteria such as:

• A high lethality attempt
• A professional judgment that the suicide risk outweighs the risk of inappropriate hospitalisation
• The patient has little interest or capacity in safety planning
• Insufficient support
• Inability to restrict access to lethal means

Psychiatric hospitalisation can provide a young person with safety, stabilisation, and through assessment and initial treatment. On the counter-argument, there is also evidence to suggest that hospitalisation may increase long-term risk due to stigma and isolation.

Treatment options
Psychotherapeutic intervention should underpin any approach to treating a suicidal young person. A number of suitable modalities are available, and with knowledge of a person’s situation, a suitable therapeutic support model can be identified. Options may include:

• Dialectical Behavior Therapy for Adolescents
• Interpersonal Psychotherapy for Adolescents
• Cognitive Behavior Therapy for Suicide prevention

Other care actions include

• Wellness planning- exercise, diet, sleep
• The development of coping skills
• Education about suicide and depression
• Safety planning and reducing accessibility to means
• Increased family support and engagement

Patient, family, and school supports
The safety plan will likely include actions for the patient and the family. Family and support networks can contribute to the delivery of the plan and be available to support the young person. Steps by and for the family may include:

• The removal of firearms and lethal medicines, including alcohol at home- a critical piece of any comprehensive approach
• Written support plans including names of key contacts
• Creation of records about the specific role of each caregiver in a crisis
• Documenting emergency services and contacts

As schools may be able to offer services and supports to young people following a suicidal episode, and it is generally recommended that school services be involved in planning and maintaining health for students. Often friends or school staff will be aware that there has been a suicide attempt. How to inform and engage with a school will vary by individual cases, and there may be other legislation and practices related to both confidentiality and school records to be addressed.

Documentation and reporting
It is important to document assessments and treatment details for patient safety, organisational procedure, and compliance. Direct quotes and observations help to create holistic documentation. The importance of creating a detailed safety plan is reiterated.

Conclusion
To work effectively with a suicidal young person, primary care providers and behavioral health nurses need the ability to create appropriate and professional relationships. They need to be empathetic and genuine and to have an understanding of the therapeutic models that might make a difference. One critical skill identified in this research is the ability to work with a patient to create a safety plan that details support and resources available to the young person.