What is Suicidal Ideation?

View the Transcript

Featured guest: Jessica Pierce, M.D., Department of Psychiatry

Objectives:

• Describe the difference between active and passive suicidal ideation
• Identify strategies to respond to someone who is reporting suicidal ideation in a medical setting
• Explain causes and triggers for suicidal ideation

Resources:

• National Alliance on Mental Illness
• NAMI Washtenaw County
• University of Michigan Depression Center
• University of Michigan Depression Center Toolkit
• COVID-19 Mental Health Toolkit - Provider Resources

CME:

Credits available: 0.50

Visit our CME course overview page for CME credit, or complete this survey for social work CEUs.

Transcript:

Dr. Christina Cwynar:

Hello, and welcome to our podcast Breaking Down Mental Health with myself, nurse practitioner Dr. Christina Cwynar, child and adolescent psychiatrist Dr. Heidi Burns, and social worker Syma Khan. Today, we are joined by Dr. Jessica Pierce to discuss suicidal ideation and self-injurious behaviors. Thank you for joining us today, Dr. Pierce.

Dr. Jessica Pierce:

Thanks so much for having me.

Syma Khan:

Dr. Pierce received her bachelor's degree in creative writing from John Hopkins University, her master's degree in medical anthropology from the University College London and her MD at the University of Colorado. She completed an internship in general pediatrics at Tufts Medical Center in Boston, psychiatry residency at the University of Washington and Seattle, and a fellowship in Child and Adolescent Psychiatry at Children's National Medical Center in Washington DC. Dr. Pierce's clinical interests include medically complex children, eating disorders, anxiety disorders, and trauma informed care. She is active in medical education and advocacy focused on child welfare system and asylum refugee care. None of the speakers here today have any conflicts of interest or financial disclosures.

Dr. Pierce, let's start very basic and broad. What is suicidal ideation and what is the difference between active and passive?

Dr. Jessica Pierce:

Suicidal ideation is thinking about suicide, thinking about ending one's life, we're thinking about not wanting to live any longer. Active suicidal ideation is having a plan or an intent to actually act on your plan and your thoughts. And passive suicidal ideation is thoughts that are generally ever present. Sometimes they come and go, but you don't really have any intent to act on them or specific plans of what you might do to perpetrate self-harm or end your life.

Dr. Christina Cwynar:

Thank you for differentiating between active and passive thoughts there. I think when we meet patients and families who are experiencing these, it kind of scares a lot of people and having that differentiation helps us in that long-term plan and treatment of these patients. Can you speak a little bit to the neurobiology behind suicidality?

Dr. Jessica Pierce:

Sure. Like the neurobiology for most things within psychiatry, suicidality is really complex. It involves interactions between genes, genetics, environment, a person's own physiology and biologic factors, and there are lots of things that we still don't understand about the neurobiology of suicide. But, there have been studies looking at autopsies of people who have died by suicide. And we see differences at the cellular level in patients who have died by suicide compared to patients who died by other means. We see differences at the neurotransmitter level, particularly with serotonin, but also norepinephrine and dopamine. And then even on studies like functional MRI where you can look at how a brain is working in individuals who have suicidal thoughts or have engaged in suicidal behavior, we see structural changes and functional differences when we're looking at brains that are coping with suicidal thinking.

Dr. Heidi Burns:

Thanks, Dr. Pierce. I think that's really interesting to think beyond the way our mind works and the real biology behind it and some of the things that might be happening on a cellular level in these patients to help us sort of understand and normalize a little bit that this process is something that is truly related to our genes and related, not only to the way our mind works, but our biology and our background and our genetics, too. So, now that we have a definition for suicidal ideation and kind of a better understanding of what it means when someone is actively suicidal versus passively suicidal, how about we talk a little bit about something that kind of gets a little bit confusing, the idea of self injurious behaviors and self harm and kind of how that compares to actual suicidal ideation.

Dr. Jessica Pierce:

Yeah, I think that's a great distinction to make. We talk about self injurious behavior or SIB, sometimes we talk about nonsuicidal self-injury or NSSI, and that comes in a lot of different forms. And what we're talking about there is essentially just methods of harming one's self on purpose. And the reasons behind that vary a lot from individual to individual. People will sometimes self-harm using cutting, so using razors, knives, blades, even simple household objects like paperclips or pencils. People can engage in self harm with scratching, just using your own fingernails. Sometimes people will use erasers from pencils to scrape their own skin. We see burning, pinching. These are all things that a person can do with relatively little access to anything other than their own hands or fingers or simple common items and cause self injury of various degrees.

And reasons people might do this would be some people say, I just wanted to feel something and when I harm myself, I feel pain and then I know that I'm alive. Or some people might use it to displace other types of pain. They're feeling significant emotional pain, so they engage in some sort of self harm that displaces that pain from emotion to a physical sensation. Sometimes people self harm as a means of self punishment and whether that's coming from their own thoughts, inferiority thoughts or low self-esteem, or if that's because they are hearing negative thoughts about themselves from people around them. So, there are a lot of different reasons and different ways in which people might self-harm, but the underlying theme is that they are causing injury on purpose.

It doesn't necessarily mean that they're at greater risk to attempt suicide. We do know that the two are related, like most things in psychiatry, it's a complex relationship. Certainly, people who engage in self harm should be considered to be at higher risk for having suicidal thoughts or engaging in suicidal behaviors, but it's not a direct correlate that if you engage in self harm, you will definitely someday be suicidal or act on your suicidal thoughts.

Dr. Heidi Burns:

Thanks for differentiating that. I think, sometimes, especially, if you're a provider or someone who's come in contact with someone who's had self injurious behaviors, it can be a bit confusing to figure out, is this something I should be alarmed about in a sense of having an imminent risk for suicide? And like you said, I think it's quite complex. And there's some research out there that talks about the idea that if you sort have crossed a threshold into self harm behaviors, that may somehow make you more at risk for having a suicide attempt in the future. So, there's a bunch of different ideas out there and research that's still going into this behavior.

Christina Cwynar:

Dr. Burns, I kind of want to jump off of that a little bit and maybe we can make a little bit of a distinction. So, we see self injurious behaviors not only in the thought of self harm, but also we see our developmentally delayed population who self-injure for I guess lack of a better term. And can you, Dr. Pierce, kind of differentiate where the concern is and how we help parents understand that aspect of things?

Dr. Jessica Pierce:

Yeah, I think that's a great point. Certainly patients who are somewhere on the neurodevelopmental spectrum may engage in self-harm as a means of self-stimulation. And self-harm, really, when you boil it down, it's a coping strategy. It's a maladaptive coping strategy, it's not one we want people to engage in because the result is they are injured in some way, probably both physically and emotionally, by doing it. So, I can't really think of an instance in which self harm is not concerning at all, but there are degrees of self harm, and you have to consider the context. And I think for parents, thinking about your child being injured in any way, and certainly at their own hands, is really frightening and something that of course you're going to want to intervene in.

I think where providers can be helpful is putting the self-harm in perspective and understanding what's driving it, how serious is it, and what is it telling us about the distress level of your child, and what we need to do to intervene to help them feel better, or redirect their emotion so that they use a different, more adaptive, coping strategy. So, that their first instinct is not, I feel bad or I feel nothing I want to cut so that I feel better or I feel something, and instead we direct them to a coping strategy that's more adaptive, like listening to music, writing, talking to somebody. So, I think for parents, the take home message is, self injurious behavior is never normal, but it is common, and it's not always an emergency and it's something that talking to providers about, we can assess what is the real threat level here and what do we need to do to help this child adapt more constructively.

Syma Khan:

I really appreciate that perspective, Dr. Pierce, of what can a parent do if their child is self injuring. Because it is frightening and concerning and parents are uncertain of what to do, and I think it's engaging your care team, engaging your child, as well, of what's going on, what are you feeling. I think providing those opportunities for other distraction, or engagement, around those behaviors is really important, too. I know a lot of DBT focuses, as well, on ways to manage those intense emotions. And so, maybe even snapping a rubber band or holding an ice cube, right? That's going to provide you that intense stimulation that cutting would provide. So, finding an alternative behavior that coping strategy to move away from that maladaptive coping.

And we throw out a lot of acronyms. So, DBT is dialectical behavior therapy, which is a form of psychotherapy that really focuses on promoting positive coping. It was developed by Marsha Linehan, and oftentimes thrown in together with borderline personality disorder. But, actually, DBT is evidence based for depression and many other diagnoses as well. And it can be really useful tool for families because it's often co-taught, where your child is getting intervention and then you're also getting resources that your child is learning or the strategies that your child is learning. So, we can share more information about that as well so that families can access that and hopefully learn more about ways to support their child.

Dr. Jessica Pierce:

Syma, you said something that I really liked, which is when parents are worried they need to engage their care team. And it really goes back to one of my standard lines for kids and families in psychiatry, which is never worry alone. And so, if there's something that doesn't feel right, isn't right, and certainly if you find out your child is self injuring, even if you discover it just because you happen to catch a glimpse of it when they had their sleeve rolled up, it's not something to just sit and stew about by yourself. And so, never worry alone means talk about it, talk about it with your child, talk about it with their care team if you have one, and if you don't have one, go find one. The school can be a good resource for that. But never worry alone, especially, when we're talking about self-injury and suicidal thoughts because you don't want to get to the point where it's too late.

Dr. Christina Cwynar:

Dr. Pierce, how would a parent talk to a child if they discovered that they were self-harming? What are some good questions or ways to approach a child?

Dr. Jessica Pierce:

I think the first thing to know is that talking about suicide does not make suicidal thoughts worse. And people very often worry about that, that if they bring it up or they ask about it or they go into it in any kind of detail, they're going to give the person ideas about suicide. And we have a lot of research that shows that's just not the case. And in fact, talking about it is a really key part of executing a safety assessment and putting a plan into place.

And so, parents and kids have their own language and it's different from family to family, but my advice is to be really open and straightforward about it. If you see something that looks like self injury on your child, in a private place where siblings are not around, ask them about it. "I noticed this thing on your arm. What happened there? Can you tell me about that?" Be open ended about it so that you're not immediately assuming it was self harm. Or if you hear from a neighbor or a concerned teacher that this is happening, you just have to have the conversation bluntly and say, "I heard this is going on. Tell me about that. Tell me what you're thinking about that. Tell me what goes through your mind, how you're feeling when you do that, and we'll see if we can find a way to help you with that."

Syma Khan:

I think there's also a lot of resources that families can access, as well. And it can be really challenging because the internet's an overwhelming place and not all resources are reputable. So, I often find that the National Alliance for Mental Illness is a great place to go for education and support and guidance on what to do and the questions to ask, as well. Because so many people worry alone, and I really like that reflection of kind of tap into other supports because this is confusing and it is scary. And part of the goal here is also to kind of help providers and families that listen to this podcast know where they can go and who are the people that they can use for support. The University of Michigan also has a lot of good education resources as well on their website.

Dr. Christina Cwynar:

Thank you Syma and Dr. Pierce for that insight. And I think in this next episode after we wrap up talking about some of the things here, we're going to get into some of the nitty gritties about safety assessments and safety planning, and we'll have more tips and tricks in that episode. But I did want to jump, kind of, back and add maybe a little bit of a tangent, but Dr. Pierce, you reflected on how individuals on that developmental spectrum can self-harm for other reasons. And I wanted to just add, I guess, a little comment on that and say sometimes when we are working with individuals who are on that neurodevelopmental spectrum at a different place than somebody who may be self-harming for reasons that they want to harm themselves, they may be indicating that something else is going on. So, if that's suddenly something that's developing, getting a medical assessment being like, oh, are they in pain for some reason, are we missing something medical going on that needs to be addressed in a different manner?

Dr. Jessica Pierce:

Yeah, absolutely. I think not only is self harm a means of feeling, but it can be a means of communicating. And so even with younger kids who are neurotypical, if they don't have the language or the emotional understanding to recognize how they're feeling and tell someone else about it, it may look like head banging or pinching themselves. And that may be a way of communicating, "Hey, I'm in distress, I need some help." So, I think that's a great point. And how we intervene may depend a lot on what is driving the behavior.

Dr. Christina Cwynar:

Now that we're done with our little tangent there, maybe we can talk a little bit about what we as providers are allowed to disclose to parents and guardians when a youth is reporting suicidal ideation.

Dr. Jessica Pierce:

Yeah. So, this is a great question and it comes up a lot in the pediatric setting. And there are privacy laws for kids and adolescents, especially age 12 and above. And in the state of Michigan, there are a lot of things that a provider cannot disclose to parents. Maybe a lot is overstating it, but there are some things, and for good reason. Aspects of sexual health, things that really need to be kept private in order to maintain that relationship where the patient will talk openly with the provider about what's going on. One really clear exception is when the patient's safety is at risk. And so, it is probably the exception to not disclose to parents when you learn that a child is self-harming or has significant suicidal thoughts because there needs to be an intervention that involves the broader system around the child in order to help them succeed.

And so, what I tell kids is I always tell them if I'm going to disclose to their parents that they've been engaging in self-harm or that they're having suicidal thoughts, and I explain the reason that we need to protect their safety, and that probably on some level these behaviors that they're engaging in are their way of saying, I need help. And that's what we're doing is we're helping them. And so I think providers worry a lot about crossing that line and it's good to give thought to that line, but really, at its core, if the child's safety is at risk, you need to communicate with the parent.

Syma Khan:

Thanks so much, Dr. Pierce. I think that helps providers know that it is okay to break confidentiality in those situations because we really need to work collaboratively and engage families as well in maintaining safety for an adolescent that may present to an emergency room. I think linked to that, a question people often have is what can people do to say or support someone endorsing suicidal ideation?

Dr. Jessica Pierce:

Yeah, and that's a big question, and it depends a lot on the situation, but I think we've talked about some of it already is listen, ask follow up questions, I think that piece gets missed a lot. Somebody hears I'm having suicidal thoughts, and then the recipient of that information is maybe paralyzed and doesn't move forward. And you need to know more about what that means. Are you having active thoughts? Are these passive thoughts? Are they chronic, meaning they've been there for a long time, or are they brand new? Do you have a plan? Ask the follow up questions. And then as far as support goes, let the person know, "I hear you. I'm so sorry to hear that you're feeling that way. Let's work together to come up with a solution, or at least resources to help you cope with these thoughts." And that's where that don't worry alone comes into play, and you need to get a broader system involved.

Dr. Heidi Burns:

And I think it's worth mentioning that we recognize, especially if this was a conversation between a parent and a child, that sometimes you're overwhelmed by the realization that this is happening to your child and your own fight or flight system might kick in and take over. And like Dr. Pierce said, you may kind of feel paralyzed, not sure what to do next, and having a rush of emotion. And so, sometimes it is good to think ahead and try to figure out those ways that you know how to self soothe and what can you do in those moments that you might be having with your child. Or if you are having a patient that comes to you with this, it can be really distressing, and how do you stay in that moment and support them and at the same time soothe yourself so that you can keep the child safe.

Syma Khan:

Dr. Burns, I think you bring up a really important point. I think it's really hard for medical professionals that aren't in the mental health field to support someone with suicidal ideation. And kind of a question for the group, is there any recommendations or things that medical professionals can say to a child that's endorsing suicidal thoughts? Because I think even providers feel very scary, nurses going into the room kind of feel scary, like they're going to make the situation worse. What can we do to help our staff and colleagues also feel like they're capable of caring for an individual in the emergency room with suicidal thoughts?

Dr. Christina Cwynar:

I think in thinking of this from a nursing perspective, I talked to a lot of nurses and I experienced it myself as a new grad. Being a nurse at the bedside, taking care of these patients is sometimes you're so scared to say the wrong thing or not sure what to say when you walk in that room post suicide attempt and you're caring for this patient, maybe on the medical side of things. And I think just remembering that these patients are people, too, and talking about things that don't have anything to do with why they're there in the moment can be a distraction for all that emotional distress that they're feeling.

Talking about things that bring them joy, or things they like to do, and finding out what those are because asking something about school may not be the right question, and it's okay if you ask that question, be like, "Hey, how's school going?" And they're like, "School's why I'm here, and why I attempted suicide.?" Okay, that's not a safe topic right now, let's talk about your favorite video game, your favorite movie, those things that may bring a smile to their face in a moment that is really hard and often filled with a lot of mixed emotions.

Dr. Jessica Pierce:

Yeah, I think that's great advice, Christina. And one thing I often tell kids who disclose suicidal thoughts, especially if it's the first time that they've disclosed that, is to say, "Thank you for sharing that with me. I know that's a really personal thing and I appreciate you trusting me enough to tell me that." And then I would say to providers who maybe don't know what the next step is, that's okay. And it's okay to even tell that to the patient, you know can say, "Thank you for sharing that with me. I'm not sure what the next best step is, but I'm going to talk to somebody who really specializes in this stuff and see how we can help you with that." And then, like you said, Christina, transition to something else. In the meantime, can I get you something to drink? Do you want to talk about your favorite Netflix show? Something like that.

Dr. Christina Cwynar:

Humor can go a long way, sometimes.

Dr. Jessica Pierce:

It's true.

Syma Khan:

For those that you don't know, dr. Pierce loves a good joke.

Dr. Jessica Pierce:

That's true. In fact, I demand that every patient tell me a joke.

Dr. Christina Cwynar:

We might have to demand one at the end of the episode.

Dr. Heidi Burns:

So, we've talked about a big topic today and lots of details around it. Are there any other thoughts?

Syma Khan:

I think this was a really rich conversation about a topic that's really hard and I think something that scares a lot of medical professionals. And so I really think it's breaking it down, so kind of taking it step by step. And I really think it's important for us to be able to distinguish when someone's having those suicidal thoughts and what we do. So, I'm glad that we could kind of start this off and I know we're going to kind of keep this conversation going on next steps in our next step episode.

Dr. Christina Cwynar:

Maybe we can end with that joke, Dr. Pierce.

Dr. Jessica Pierce:

Oh, sure. Okay, do you want to hear my knock joke or my Pokemon joke?

Dr. Christina Cwynar:

I'm going to go with Pokemon one.

Dr. Jessica Pierce:

Okay. Why can't you take Pokemon into the bathroom with you? Because he'll peek at you. It's a lot of groans happening right now. These are children's hospital jokes.

Christina Cwynar:

Yep. Keep it G, maybe PG.

Syma Khan:

We know our audience well.

Dr. Heidi Burns:

Thank you so much, Dr. Pierce. We truly appreciate your time and expertise, and dad jokes.

Dr. Jessica Pierce:

My pleasure. Thank you for having me.

Dr. Heidi Burns:

And thank you to everyone that tuned in this week.

Dr. Christina Cwynar:

And to nurses, social workers, and physicians, you can claim CMEs and CEs at uofmhealth.org/breakingdownmentalhealth. You're able to do this anytime within three years of the initial air date.

Dr. Heidi Burns:

We hope that you'll join us next time when we will, again, be joined by Dr. Pierce as well as pick the brain of our wonderful social worker, Syma Kahn, and discuss safety assessments and safety planning. See you then.