Opinion & Essays -
September, 2001 Issue #85
Understanding and Dealing with
Self-Harming and Suicidal Behavior
By Michael Conner, Psy.D
Mentor Research Institute
[Dr. Conner, a clinical and family psychologist, has completed
a research and training fellowship in Graduate Medical Education at Kaiser Permanente and has worked in emergency room psychiatry,
inpatient crisis intervention, community crisis intervention, school crisis response, outpatient mental health and law enforcement.
Dr. Conner has National Board Certifications in Emergency Crisis Response, Emergency School Response and Traumatic Stress.]
Alternative intervention and education programs have grown as a free market solution
in direct response to a failure in the public sector to provide adequate intervention and educational services. Wilderness therapy
programs, wilderness boot camps and boot camps offer intervention services for parents of youth at risk who have special needs. Most
of the children in need of intervention have mental, emotional and behavioral problems ranging from mild to severe.
Transition boarding programs, therapeutic boarding schools and traditional boarding schools provide transition experiences, follow-up
services, remedial education and college preparation opportunities. What began as a cottage industry consisting of quality alternatives
has become a fast growth industry where parents are enrolling children who may have problems beyond the skill of these programs.
Depression, Anxiety and Suicidal Behavior
In 2001, the U.S. Surgeon General reported that one out on ten teenagers have mental health problems ranging from depression to schizophrenia.
Only one out of three of these children receive appropriate mental health services. Nearly three out of ten children suffer from symptoms
of anxiety and depression. Symptoms of anxiety and depression are contributing factors as well as the consequence of family, social
and academic problems.
Along with symptoms of depression and anxiety come other more serious problems including self-defeating, destructive, violent, self-harming
and suicidal behavior. Suicide is the second leading cause of death among teenagers. The risk of suicide or self-harming behavior
in an intervention, transition, treatment and educational program is no less than the risk in society.
A completed suicide is very rare in comparison to the number of children who consider or attempt it. Programs need to recognize that
the assessment of risk and the intervention can be entirely negligent and a child will still not attempt suicide. This illusion of
success can give professionals and programs a false sense of confidence in their response. Re-examination of staff recognition and
responses to a suicide risk is indicated when a program is operating on the basis of popular beliefs, potential myths or evaluation
and intervention procedures that have not been reviewed by a qualified, trained and experienced crisis intervention professional.
Why Do Children Attempt Suicide?
Nearly a thousand articles and books have been written about the cause of suicide as well as appropriate interventions and prevention.
There are essentially six reasons why children attempt suicide. Understanding these reasons can help you recognize the risk of suicide:
- Change: Suicide is way for the child to change how he or she feels or what is happening at that moment. Suicide is an escape
from life. Suicidal behavior is a means to avoid events, feelings or problems.
- Choice: Suicidal behavior is a means to assert or make a choice during circumstances in which there are no choices, or important
choices are being taken away. Suicidal thoughts and behavior can be a response tendency when children face the loss or pending loss
of choice and freedom.
- Control: The suicidal act is meant to stop one’s behavior, to control events or to effect some change in others. Suicide
and suicidal behavior can be a means to control self or others.
- Self Punishment: Suicidal behavior is a means to relieve guilt or punish one’s self for one’s actions. The child believes
he or she deserves to die.
- Punish Others: The suicidal act is intended to inflict harm or punishment on others. This includes revenge.
- Psychotic Illness: The suicidal act is the result of strange and bizarre beliefs that are caused by a mental illness or a
severe medical problem affecting a child’s mental status.
What Are The Critical Suicide Risk Factors?
Recognition of a suicide risk begins in a relationship where a child exhibits or reveals critical information to a friend, trusted
staff member or mental health professional. Ignoring Critical Risk Factors or the unqualified dismissal of these risk factors would
almost certainly be negligent.
Suicidal “like” behavior is a complex emotional, cognitive and behavioral problem to understand. Not all suicidal behavior is motivated
by a desire to die.
Children may become para-suicidal (e.g. self-destructive) for reasons other than a desire to die. For instance, self-mutilation is
often motivated by a compulsion to escape emotional pain.
There are many professionals who believe that the death of children is often the result of para-suicidal behavior. A drug overdose
where a child changed their mind can lead to liver failure several months later. Or a child can become so overwhelmed with a sudden
loss of freedom and control that he or she will jump out a window. Whether suicidal or para-suicidal, critical risk factors must be
considered critical because children can and do die during such behavior.
Asking a child if they are feeling suicidal does not increase the risk that a child will become suicidal. At worst, they may act suicidal
to punish others or regain the illusion of control in their life. But an insensitive or sarcastic response to a para-suicidal state
can increase the risk of suicide.
The following are critical risk factors that you should listen and look for. These are also questions that you can simply ask a child
- Are you wishing you didn’t exist?
- Are you thinking you would like to go to sleep and not wake up?
- Are you thinking about death a lot?
- Do you think or feel like you would be better off dead?
- Do you think about suicide or feel suicidal?
- Have you made plans or are you thinking about plans to commit suicide?
- Have you acted suicidal or done anything \ dangerous or self-harming?
Duty To Protect and To Insure Proper Care
The death of a child as a result of suicidal behavior is the fault of an intervention, transitional, treatment or educational program
if the program:
(1) ignored or did not recognize evidence of critical risk factors,
(2) did not obtain a face to face evaluation and intervention plan from a licensed professional who was trained and experienced in
dealing with the risk of suicide.
Successful litigation, case law and licensing board decisions across the country demonstrate an unmistakable trend in which professional
associations and juries expect professionals and programs to act within professional guidelines and standards of practice. Juries
and legislators get involved when programs and professionals do not establish or follow a reasonable standard of practice. Statutory
laws have been passed in some states to codify performance expectations. The challenges facing programs are issues of negligence,
due diligence and standard of care. Negligence can be defined as the four D’s: Dereliction of a Duty Directly lead to Damage. Diligence
is nothing more than persistent efforts directed towards an expected action. Standards of care are established guidelines for conduct
within the profession providing services, or guidelines that would be expected based on a similar profession.
Ethical requirements for professional licensure, also statutory and case law nationwide, demonstrates that professionals and programs
have what is called a “duty to care” and a “duty to protect”, especially in the case of abuse or dangerousness to self and others.
In the case of violence, programs and professionals can be mandated to take actions that would responsibly protect an individual and
the public. Merely reporting concerns to responsible agencies and individuals in not necessarily enough. Failure to have a child evaluated
by a qualified professional is negligent. Negligence with regard to professional and program responsibilities is a growing area of
concern for those facing the risk of suicide.
Some programs feel the best way to minimize their liability is to avoid hiring licensed professionals who would demand a higher standard
of care in order to protect their license. For example, I am aware of an event where field guides in a wilderness program denied a
qualified crisis intervention professional access to a suicidal child who was their client. The field guides insisted that they could
handle it by themselves and that they did not need the child’s counselor. While only a few programs may avoid and minimize their duty
to care and protect, I believe consumers will applaud and have confidence in programs that respond to these issues by offering competent
practices and a culture of professional awareness.
Dealing With The Risk of Suicide
Popular ideas and myths about suicide and suicidal behavior are rampant in society. Suicidal statements and behaviors are often minimized
or dismissed as “attention seeking”, “manipulative”, a “cry-for-help” or a “refusal to face feelings”. While these characterizations
may be correct in some instances, they are often used in a derogatory way that is based on superficial impressions. Superficial opinions
are not only unresponsive to children on the verge of self-destruction, but they foster a professional culture that borders on systematic
Therapeutic activities within a program must be appropriate to the needs and vulnerability of children. Some program activities carry
inherent risks. Those involving unpleasant, aversive and punishing consequences such as depravation of social interaction or corporal
punishment are high risk interventions that can result in violent, destructive, self harming and suicidal behavior. These approaches
should only be authorized by a qualified professional who has an appropriate treatment plan that is based on a qualified evaluation
made in consultation with the child’s parents.
The standard of care for a program facing a suicide risk should reflect the highest professional practices, that are developed by
qualified professionals trained and experienced in addressing the risk of suicide. Policies, procedures and training can be professional
and realistic, and should be developed by consulting with professionals who understand the program’s resources relative to the children
A common risk management policy used by programs is to refer to Emergency Departments (EDs). But realistically, managed health care
has created road blocks so that hospital responses are minimal and staff literally refuse the admission of a child who says he will
not kill himself within the next 24 hours. Except in the case of active suicidal behavior, it is not enough to rely on community mental
health or hospital emergency departments for evaluation and intervention.
Counselors and therapists as well as medical and mental health professionals are not necessarily more qualified to evaluate and deal
with a risk of suicide than a reasonable person. Physicians are trained to diagnose and treat medical conditions, medicate if necessary,
and admit patients to holding or psychiatric facilities. Evaluation, intervention and treatment of a suicide risk are specialized
skills that require training and supervised experience.
Program personnel should consider themselves responsible for the outcome, when the program and its staff assume the authority to intervene
or dismiss the risk of suicide. The evaluation of a suicide risk is in fact an intervention and that intervention should not end once
the child’s risk is no longer considered immediate. Consultation with parents and obtaining second opinions from qualified professionals
are reasonable standards of practice.
A minimally qualified professional to deal with a suicide risk would have,
- a masters degree in a mental health field,
- licensure in mental health field,
- 16 hours of continuing education training in crisis intervention (with emphasis on suicide and violence risk), and
- 6 months of supervised experience and training working with suicidal adults and children on regular basis.
Professionals with minimal qualifications should also consult on a regular basis with a professional who has expert skill and experience.
Programs have a duty to insure proper care, which is clear if the child displays any critical risk factors. Programs must be vigilant
if the admission reveals a history of a previous hospitalization or residential treatment, the child is on medications for a psychiatric
condition, or there is a history of dangerous or self-harming behavior as well as failing social and educational performance. Programs
must proactively examine the potential interaction effects between each child and program structure before and after admission. Supervision
or consultation with a qualified person as well as face to face evaluation are essential when staff are not qualified to deal with
a risk of suicide.