Adolescent Suicide Prevention 101: Bringing the Science to Families, Teachers, and Pediatricians/Webinar by Professor Pamela Morris-Perez, PhD, New York University, February 15, 2023, Full Transcript

Adolescent Suicide Prevention 101: Bringing the Science to Families, Teachers, and Pediatricians/Webinar by Professor Pamela Morris-Perez, PhD, New York University, February 15, 2023, Full Transcript

Capitalized, punctuated, speaker labels added, and timestamp added by Emily Kha

[00:00:03]
CHIH-CHING HU: Hello everyone. Welcome to Alan Hu Foundation Mental Health Lecture Series. I am Chih-Ching Hu, Co-Founder of Alan Hu Foundation and host for your webinar. Today, Dr. Pamela Morris-Perez will present “Adolescent’s Suicide Prevention 101: Bringing the Science to Families, Teachers and Pediatricians”.

[00:00:28]
First off, I want to thank the Mental Health Association for Chinese communities for providing simultaneous Chinese interpretation. And thank you Ida Shaw for Chinese interpretation.

[00:00:40]
Alan Hu Foundation’s mission is to promote mental health, raise awareness, and remove stigma surrounding psychiatric disorders, and support fundamental research for cures. Please consider making a gift to the Alan Hu Foundation by scanning the QR code on the slide or using the donation link in the chat box. Thank you for supporting our programs to promote Mental Health.

[00:01:09]
Today, it is our great honor and privilege to introduce Dr. Pamela Morris-Perez.
Dr. Morris-Perez is a professor of Applied Psychology at NYU Steinhardt School of Cultural Education and Human Development and Affiliated professor at NYU School of Global Public Health. An interdisciplinary scholar, Dr. Morris-Perez conducts research at the intersection of the developmental psychology, suicidology, education, and the policy.

[00:01:43]
Her newest research, born from the loss of her 17-year-old daughter to suicide in 2019, addresses adolescent suicide from a developmentally informed, population-health perspective for suicide prevention. She brings prevention to the spaces where youth are—schools and emergency departments—to help more youth connect to care more quickly.

[00:02:04]
In this presentation, Dr. Morris-Perez will offer an introductory understanding of adolescent suicide and prevention. The goal is to empower parents, teachers, and pediatricians to have the knowledge to ask and to respond to adolescence suicidal thinking, and to help more adolescents get the care they need more quickly in hope that doing so will save more lives. Following the presentation, there will be a Q&A session. Please submit your questions using the Zoom Q&A function. The presentation is for educational purposes only and it is not intended for medical diagnosis. If you have any persistent symptoms, please seek professional help. With that, I’m going to turn to Dr. Morris-Perez.

[00:02:58]
Welcome Dr. Morris-Perez.

[00:02:59]
DR. MORRIS-PEREZ: Thank you so much for that wonderful introduction, and thank you for hosting this. I’m going to share my screen, and play my slides. There we go, we can all see that, right?

[00:03:13]
CHIH-CHING HU: Yes.

[00:03:14]
DR. MORRIS-PEREZ: Perfect. Thank you. Thank you again for that wonderful introduction. Thank you for all the work you’re doing to support mental health awareness and for bringing me here today. Today I’m going to be talking about adolescent suicide prevention. I want to thank all of you who’ve decided to come here today. This is not an easy topic and you’ve made a hugely courageous first step just in coming to hear this talk. I want to thank Rachel Abenavoli at NYU, Stan Collins and Jana Sczersputowski, Directing Change; All colleagues who I work closely with who have really informed the work I am going to be talking about today.

[00:03:46]
So I’m sure you’ve heard about rising rates of anxiety and depression and suicidal thinking among our young people as a result of Covid-19. I’m sure you’ve heard about that in the news, especially this week. It wasn’t Covid, as you heard, that got me into this work. I was actually drawn into this work before Covid from my personal experience. My story actually begins 11 days after 9/11 when I was blessed with beautiful boy-girl twins. The two were perfect playmates for each other and compliments for one another. My son, the engineer, lanky and quiet. My daughter, Frankie, was the humanist, the pixie, with the sort of magical ability to connect with others. And the two would walk like this down the street. This is on our block. And I would walk behind them and just feel like the luckiest of parents.

[00:04:34]
But that life was shattered when Frankie took her life, as you heard, at age 17. It was about three weeks before her high school graduation. This was three and a half years ago now, back in June of 2019.

[00:04:46]
As a parent, of course I had a million questions after she left us. But as a prevention scientist—so I’m trained as a developmental psychologist that studies prevention programs—Those questions focused on how the world might look differently, so another family wouldn’t have to go through what we did.

[00:05:04]
And so I began learning everything I could about adolescent suicide and suicide prevention. And the more I learned, the more I realized everybody needed to know for us to make progress together in prevention. But first in this new world I was really confronted immediately with a new language, so I learned that suicidologists—the people in the suicide community—don’t use the word “committed suicide”.

[00:05:26]
And this picture shows the sort of wretched history of suicide and the reason why suicide for a long time was criminalized and considered a sin. This is a picture of a church; I believe in England. The line you see on the grass, used to have a fence, a gate, separating the gravestones of those people who died by all other causes and separating those people who died by suicide.

[00:05:52]
And while it’s no longer a crime, and in many religions no longer sin to attempt to take your own life, that history is actually not terribly far behind us, and so the language we use still sort of carries that forward. And it’s why there’s really encouragement to use the words “died by suicide”. Just like you’d say somebody “died by cancer” or “died by heart attack”, they say “died by suicide”.

[00:06:16]
I learned that someone that like myself, who’s lost someone to suicide, is a “suicide loss survivor”, someone who’s attempted suicide can be called a “suicide attempt survivor”. Just like Holocaust Survivors, we’ve gone through sort of an emotional trauma and come through to the other side. And so it’s really articulating that. Suicidology is the scientific field for the study of suicide. And Suicidologists study three things. They study intervention programs. Those are programs for people who’ve already been deemed suicidal as a result of receiving a diagnosis by a mental health clinician, prevention programs, and that’s what I’m going to be talking about a lot about today, at prevention of suicide. And postvention, which is a supports for suicide lost survivors, where actually we need a lot more work. We need some guidelines but we need an increasing number of programs for that. But that was really just the tip of the iceberg in terms of what I learned, in terms of what is a new language.

[00:07:11]
I also learned that there was an exceptionally high prevalence of suicidal thinking among our young people, that one in five teens report having seriously considered suicide in the last year, one in ten teens have reported having attempted suicide in the last year.

[00:07:27]
So this is a picture of a sort of very typical high school classroom. That means like in a typical high school classroom we might have five kids who are thinking about suicide or thought about suicide in the last year, two to three kids who’ve attempted suicide in the last year. Those numbers are as you can see very high, and what you might be saying is “Well of course. That’s because Covid has really brought so much harm to our young people.” Actually, these data are from 2019. New data actually just came out this week; It shows that those numbers are just slightly higher than that now. So it used to be a little below one in five kids. Now it’s a little above one in five kids. So that mental health crisis that you’re hearing so much about in the news right now honestly was very much around us pre-Covid. We just started paying attention post-Covid.

[00:08:18]
I also learned uh how much kids can camouflage their emotional pain, that it’s not surprising to have a child like Frankie, who can keep their suicidal thinking to themselves for an exceptionally long time. I also was surprised to learn how unpredictable suicide is based on risk factors. So study was done back in 2017 looking at 50 years of research about risk factors and, do they predict thoughts and behaviors around suicide? And it turns out that even though we’ve been doing this work for 50 years, we are no better at predicting suicides than flipping a coin. And that work hasn’t gotten better over the last 50 years.

[00:08:53]
Okay so and it was the combination of that very high prevalence that I told you about among young people, and that lack of prediction by researchers that argued to me that we should complement really important work that’s going on in the formal mental health system with programs in the spaces where kids already are: in schools and emergency departments, in pediatric offices and in homes.

[00:09:20]
But it’s very hard to prevent what we don’t understand. And so one of the first questions I’m often asked when I talk about this topic is “What do you think causes suicide?”. And I could give you all the theory and all the research, but actually I’m gonna instead show you this picture, which is a game that some of you might recognize.

[00:09:37]
It’s actually the game of Jenga. In Jenga, there’s a tower of blocks and the object of the game is to not let the tower fall. You actually keep pulling out blocks one by one—everybody who’s playing the game—until the last person pulls out the block and the whole tower falls down, right, and so that person lost the game, right? But of course it was all the blocks that led to that last one that really led to the tower falling. And in much the same way, suicide, which can be caused by mental illness, loss, and trauma. It’s really the combination of all of these things. There are many, many, causes of suicide from the biological—what we’re born with—and with the onslaughts we’ve had over the course of our lives, and environmental onslaughts, and all of them interact in a sort of a perfect storm, that sort of together, sort of contributes to suicidal thinking and behavior.

[00:10:35]
For many, the idea of suicide actually eludes us. How can somebody actually want to die? Well, doesn’t that go against a sort of basic human instinct will to live? And it turns out that suicide is actually not really about—for many people—not about wanting to die. It’s about wanting to end severe, unrelenting emotional pain. So just as we’re hardwired to pull our hands away from a burning stove to avoid physical pain, we are simultaneously hardwired to avoid emotional pain as well. And suicide really is a reaction to that. So suicide can then be understand sort of as part and parcel of the human condition, as somebody in unrelenting severe emotional pain seeing no other way out of that pain.

[00:11:21]
So our role then is those people who are around young people, right, as teachers and parents and doctors, is to do what we can to relieve our teens emotional pain, to relieve that unrelenting emotional pain, right, to help teens find other ways for relief, sort of alternatives to suicide—and I’m going to talk a little bit about that—and then help teens find their own reasons for living. Particularly for the tasks that adolescents are actually developmentally supposed to be engaged with. That they’re grappling with already. Questions about identity, Who am I? and purpose, like what’s my place here on this earth? Right, and meaning, why is this a thing that I’m doing so important for who I am, and what I’m doing here? And all of those things that we do can help reinforce that tower, reinforce that Jenga Tower.

[00:12:11]
Now in trying to understand prevention, one of the first things I did—and I’m going to do this relatively quickly—was, I look to other stigmatized conditions because I think some of the lessons were instructive. And I remember I was walking down the street one day and I saw this big sign as it’s in lower Manhattan, I live in New York City, on Houston Street, Ralph Lauren proclaiming their commitment to cancer research. They said “Join us in our 20-year fight against cancer.” and I thought, “Wow. How did cancer, how did the cancer movement move from a disease that in my parents generation people would whisper about it, right, “She’s got cancer”, to become a disease where a private company would celebrate its 20-year commitment?”.

[00:12:53]
And part of that happened, and I read The Emperor of All Maladies, which told me some of this, part of that happened through articulating, really pointing out the language we were using around cancer and then later AIDS. Susan Sontag wrote what’s wonderfully about all of this. And the impact it has on all of us in the public and researchers too, about the ways in which we study diseases and think about disease. There’s this wonderful quote in the book she says, “Supporting the theory about the emotional causes of cancer is a growing body growing literature and body of research, and scarcely a week passes without a new article announcing to some general public or other the scientific link between cancer and painful feelings.” Right, you’d be surprised but this was actually in the late 70s, Johns Hopkins articles, and others articulating a link between personality factors, and depression, and cancer, because we didn’t know what caused it, so we basically bundled it with all the other things we were scared of as well. So we really linked it to depression at the time and thought that was a causal link. Okay, so we’d be surprised by that now, but that was then, and really important.

[00:13:58]
And then some of the ways we changed the conversation—that we got Ralph Lauren to the table—was through something called the “Jimmy Fund”, which is a radio program. I encourage you all to hear it. I don’t have the time to actually play it here, but essentially they took a kid, no last names, they just called him Jimmy, no last name, no prognosis as a kid who had cancer. They actually talked not about his cancer, or his cancer treatment, or the fact that he is really struggling. They talked about his love for the Boston Braves, a baseball team. They actually bring the entire team into his hospital room, they try to raise money for a TV. Basically they say, “We’ll raise twenty thousand dollars. If we raise twenty thousand dollars, he can have a TV to watch the baseball game.”, and they ended up raising a couple hundred thousand dollars. And what they realized in doing that is the ways in which once you transform politically and publicly, sort of how we think about disease, and we bring hopeful messages to the table, people come to the table for for prevention, to really support it.

[00:14:53]
I was reminded by autism, and how parents were blamed as being refrigerator mothers, until we really learned that there was an underlying neurobiological disease that was linked to autism. And suicide I think has come a long way. We are talking about it more. You invited me here today, but I don’t think we’re far enough. And I bring, sort of as an example, an article that came out about a year ago now, about the former head of NIMH, Insel, who wrote a book called Healing. Sort of it’s a book where he really articulates the ways in which we haven’t done enough yet for people with mental illness. But it was this quote at the end of the article that really struck me. He says, “I want to ring the bell to tell people we can do so much better today, and there’s no excuse for allowing people with these brain disorders to languish on our streets like this and die at age 55, eating out of trash bins.” And I just want you to look at the language he’s using to talk about people with mental illness. He’s not talking about his brother or sister, his mother or his child or grandchild, right? He’s describing it as somebody who’s eating out of trash bins. And I think until we are talking about the Jimmies, and the Frankies and, the Alans of the world, and talking about and sort of elevating hopeful stories as well about people who’ve attempted and made their way through, I don’t think we can make progress in prevention.

[00:16:15]
I look to models in other areas of work. And I will get to suicide prevention in a second, but first I was really struck by some work that was done in the industrial accident literature. So a guy named James Reason wrote this wonderful set of things working with like nuclear power plants and other places, and basically came up with this thing called “The Swiss Cheese Model”, which I think is a beautiful analogy about how we think about really prevention of things that are really hard to predict and rare events. And he basically said we can’t change the human condition. We can change the conditions under which humans work. They talked about changing organizations by layering approaches to the sort of cheese approach. And so it’s basically layering them in a place where we expect those risks, right? We actually set up our environments assuming that those holes do exist, but the layers make a difference.

[00:17:05]
And I started writing about all of this through a series of pieces that I entitled what ifs. These were named after the relentless thoughts that were plaguing my sort of every waking moment after we lost Frankie. The first one was really: What if we approached suicide prevention the way we do car accidents? It was renamed by an exceptionally wise editor who came out in the Times, now, a couple years ago. And basically I was struck in writing that about our history of seatbelt safety; that’s very much where we are right now with suicide prevention.

[00:17:36]
So back in the 80s when I was growing up, we were really worried about young inexperienced drivers dying in car accidents, kids dying in car accidents. And the solution; We had seat belts. But not that many people used them. It turns out only 15 percent of people back in the 80s used seat belts. And what we did was we created a system of protection where people could get trained, and driver’s ed, that those beeping sounds come on so that you put on your seatbelt. You don’t forget to put on your seatbelt every single day. Signs on the highway remind you “click it or ticket”. Right? Regularly put on your seatbelt.

[00:18:10]
And I started to think about how we could do the same thing in suicide prevention, so that pediatricians, and orthodontist, and school personnel, and parents, and peers together can all understand how to recognize the signs, how to find the words to ask directly the question: Are you thinking about suicide? And I’ll talk about that in a little bit. And connect kids to care and provide safety, okay? So it was really sort of this layered approach.

[00:18:35]
So now directly back to suicide prevention. So a key part of suicide prevention are something that are called hotlines, or help lines, or lifelines. So in this country we have 988, which is actually the number now. It went from a ten digit number to a three-digit number. But helplines actually exist all over the world in many, many countries, and they are phone numbers that people can call to receive immediate emotional support so you don’t have to feel suicidal. If you just need somebody to talk to because you’re struggling emotionally you can call these helplines in many countries.

[00:19:10]
Now with suicide prevention they actually started with this gentleman named Chad Varah in 1952 in the UK. So, he was sort of the impetus behind that. 17 years before in 1935 he had officiated at the funeral of a young girl who had taken her life when she got her first period. She didn’t know. She thought something was terribly wrong with her. She was 13 years old. She had no one to tell her it was a completely normal part of puberty. So, he, after officiating over her funeral, 17 years later, he decides to invite, made a public announcement asking those people who were suicidal to come and speak with him. And he was really good at what he did. It’s a crowded office all of the time, and eventually he had to hire some volunteers to sit with these people and, I guess, give them tea or other kinds of things to sit with these people and wait with them while they were waiting to see him. One day, he opens his door and realizes that the crowd is largely dissipated. And he’s thinking, what happened? What magical thing just happened between my volunteers and these people? And that magic, it turned out, that helped that crisis abate, he came to call “befriending”. And the people that did it, “befrienders”.

[00:20:24]
I wish all of our help lines were called befriender lines. I think more people would call them, in fact. But it’s basically based on active listening, acceptance, understanding, and empathizing, but no giving advice and no counseling. And I tell you that full story for two reasons. One is that you know what help lines are, you’re not so scared to call them, you’re not so scared to share the numbers, to really demystify them, and secondly, to demonstrate that if volunteers in an office working with Chad Varah, no training, can actually ease pain, you can do this too.

[00:21:02]
So what else works in suicide prevention, what works universally, and I’ll get to some things you can do in a second. Well, turns out that accepting policies really matter. So wonderful work on same-sex marriage laws, that when they passed in States, they actually reduced suicide risk among young people, particularly LGBTQ+ young people. Keeping people safe really matters, both at the population level, right, in neighborhoods, but also in your homes. I’m going to get back to the home one later. But in neighborhoods if we build, if we put barriers, up in buildings or nettings up, it really matters. Firearm restrictions do matter, do work, wonderful work in the UK for one at a time pill packaging, right, so less likely to take lethal medications. Safety planning can make a difference, and I’m going to show you more about that in a little bit, as well.

[00:21:50]
Screening matters. Screening works. It turns out that if you screen in pediatric offices, and in general emergency rooms, you can make a difference in identifying kids who are suicidal. And it’s not enough to just screen for depression, so a lot of pediatric offices screened for depression or anxiety. You miss about a quarter of kids or a little bit more by only screening for other mental illnesses, but not asking directly about suicide.

[00:22:15]
Turns out parents and youth see this as really acceptable. And there’s really lovely like four item screening tools that you can use that are from the NIH. Columbia also has a wonderful tool. And then after you screen somebody and they screen positive you can actually link them to interventions that can make a difference. And one of the other pieces you can do is really go and text, and phone follow-up. So following up with a kid who’s been in your office to say, “Hey, just following up to get you connected to care, just checking in. How are you feeling?” That text and contacts can actually make a big difference, especially in the first few months after a child has had a suicide attempt.

[00:22:53]
Community-wide prevention can matter. There’s a wonderful effort, something called the Garrett Lee Smith Memorial Act. It gave money to communities to spend on suicide prevention in a variety of different ways. It turns out that made a difference to reducing suicide rates in those communities.

[00:23:10]
That was a law that was passed in the Bush era. Now we have something called STANDUP, that Biden assigned into law, wonderful similar initiative, no money behind it yet. One thing you could all do is try to get more money behind the STANDUP initiative, to really invest in communities and community suicide prevention.

[00:23:30]
I’m a developmental psychologist, but I do a lot of work in school. So I really care about what’s happening in school buildings, and it turns out that it’s actually a very nascent field. But there are some good things going on. So there are programs that try to train teachers to improve teacher knowledge about suicide. That helps. It does make teachers more aware of what’s going on, maybe even able to ask the question, identify kids. It doesn’t usually help kids know how to come to teachers directly. It doesn’t help student help seeking. Kids are not asking for more help.

[00:24:03]
We typically also haven’t seen reductions in suicidal thoughts or behaviors because we don’t study it, unfortunately. So really good first step, not enough. More importantly, are programs actually that are working directly with kids, because it really matters to actually target things directly to kids. Kids are the first to often learn about suicidal thinking of their friends, especially for adolescents. Not surprising, right? And so programs that target kids directly do seem to make a difference. There’s several out there. I’m going to tell you specifically about one.

[00:24:33]
The ones that seem to work are really building on what we know. I as a developmentalist, and people that are studying neurobiology of adolescence, know make a difference for young people, most importantly they’re really targeting peers. We all know, anybody who’s worked with a young person, knows how important their friends are to them, right? So really targeting that friend-to-friend relationship. And we tend to focus, as adults, so much on the negative things kids are doing for each other. Peer pressure, right? Turns out kids are hugely important positive influences as well. Wonderful studies of that around safe driving. Peers set norms for each other. And they can set norms around talking about mental illness and seeking help from adults as well. And that’s some of the things these programs are really trying to change.

[00:25:20]
Very quickly, I’m going to just show you something that we’ve also learned about the adolescent brain. So we used to think about the adolescent brain—this top figure—is sort of a two-part system where the cognitive control system—the rational part of the brain—was being outweighed by this really big red circle here, the social emotional system. So the idea was we need to like, you know, help down regulate all the emotions so that we could give more power to the rational side of their brain. Well, it turns out that actually, adolescent brains might be three parts. They have the control system—the rational part—the amygdala is the social emotional system. So all those emotions are definitely there. There’s another part of the brain that might be more powerful than either one of those. That’s something called the approach system. And what that means is that, essentially, and you all know this, adolescents like things that are a little bit risky. They all like new experiences, right? And so it argues that they need that for their brains. But we need to give them positive risky experiences to engage in so they don’t engage in negative risky experiences, like getting up on stage, or trying out for a team, or you know, doing public speaking, right? Things that are a little bit scary but that they can succeed at can really give them confidence and sort of building that out. And it turns out social rewards carry a particular weight. So when they have to do it for a friend, right, it carries a lot of salience for them. It’s really important to them.

[00:26:38]
So one of the things we try to do in some of our programs is help kids know how to break codes of silence and bring a kid to an adult. Scary thing to do in terms of the relationship, really important sort of risk-taking behavior. Different kind of risk taking than we usually think about.

[00:26:54]
Most importantly, as always, I was really inspired by Frankie’s friend community. Frankie is a very artsy kid, spent a lot of time in her theater office. It was tucked behind the sixth floor of a large and bustling New York City High School. It’s where she had lunch, and threw her backpack, and snuggled in a pile of teenagers. But it’s also where she hid. There was a little corner of that office where she hid when she was struggling emotionally. Once a girl that was a year younger than Frankie went there one day to cry. She was upset about something about school or something about teen life. And she told us how Frankie had gone and just sat with her in that space, and just by sitting with her, Frankie had really helped sort of ease her pain. And so then the fall after Frankie left us, she was still in school and went and rebuilt that corner. She put Post-its all over the wall with words like, “it matters”, “you matter”, and “it gets better”, and phone numbers to call for help. And so, really changing it into a love vestibule, as she called it. When I was looking for prevention programs, I really wanted those that would mirror what I saw in Frankie’s friend community; A set of kids who could build a space with support, and affirmation, and healing.

[00:28:13]
And that brought me to a program called Directing Change. So, Directing Change is a suicide prevention program that’s disguised as a film contest. This exists in California. Many of you are from California right now. This actually exists there right now. Any kid between the ages of 15 and 25 can actually submit. Make a very short 30 or 60 second film in mental health awareness or Suicide Prevention, submit it to a Statewide contest. This year the contest is almost closed but they have a monthly art contest as well. Very clear rules about how to make sure the messages are safe. The program is growing exponentially. And then a few years ago the developers packaged it for school. So rather than just a single kid working with a single teacher, a teacher would do an entire classroom of kids in creating those films. And they submit them all to the contest and they share them with their schools. And I’m going to show you a film because I think it’s the best way for you to learn what the program’s all about.

[00:29:20]
(beginning of the film)
CONCERNED CLASSMATE: Pick up, please.
DISTRESSED CLASSMATE VOICEMAIL GREETING: It’s Alex. You know what to do. (beep sound)

[00:29:24]
CONCERNED CLASSMATE: Hey bro. Um, look I’m just gonna be totally honest with you right now. Um, you know I’ve noticed that you’ve been acting weird for a few weeks now, and that you didn’t show up to school today. Um and I’m just starting to get really worried about you. I gotta ask, are you thinking about suicide at all? I mean I realize you can’t answer that question because I’ve been on the phone but-

[00:29:49]
CONCERNED CLASSMATE: Um look. If you’re listening to this right now, just please dial a number. Just call that number before, you know, you make a decision. Look there are people here to help you go through this, you’re absolutely not in this alone, okay? I’m here for you too. Um I’m gonna, I’m gonna try your house and see if you’re there, okay?

[00:30:13]
ORANGE COUNTRY CRISIS LINE OPERATOR: Orange County Mental Health crisis line. My name is Chris. How can I help you today?

[00:30:18]
DISTRESSED CLASSMATE: Hi. um-
(end of the film)

[00:30:21]
DR. MORRIS-PEREZ: Kids are amazing, right? Very, very, powerful film, sort of take my breath away every time I see it. They are safe. They are positive. They’re action-oriented films. These are kids speaking to other kids in the language that they speak, right? Not the adults trying to figure out how to speak to kids, but kids speaking to other kids. The films all look different because the kids come from different communities and different families. And they are basically teach their friends three things: How do you recognize the signs of suicide? How do you find the words to ask the direct question: Are you thinking about suicide? And then connect your friend to care. In this case, they connect them to the 10-digit number that’s now 988.

[00:31:09]
What’s really neat is, in the school-based program you could do it in lots of different ways in your classroom. So any teachers that are out there, they actually can do it in a video production class, right? You can make films, right, as part of PSAs. You can do it in a first year seminar for all freshmen or advisory periods. You could do it in an English class and talk about how you tell a story. And in fact, they’ve got lesson plans online. They’ve got films online, directingchange.org has all of this information resources for schools. Please check it out. If you’re in California, I will say please feel free to reach out to me. We’d love to involve you in the program as well or connect you to our colleagues who are doing this work.

[00:31:48]
It’s really cool because it has kind of a Swiss Cheese model, right? So that kids are learning about suicide prevention for their filmmaking, but their friends are learning with them. We’re affecting schools by advisors supporting the kids. Sometimes kids go home and work with their families on the films. Families are sometimes actors in these films. It involves the communities. Films are viewed and judged by members of the community and then, in fact, it affects the sort of larger environment as well, as these kids are mentored to become the next generation of Suicide Prevention Advocates. So it’s a program that starts with kids but really goes through that full layer of Swiss cheese, right? And back, reinforces the learning that these kids, they’re not doing it alone.

[00:32:27]
We spoke to some kids and I’m going to do this very quickly. Some kids, students, and advisors about the program, and these are some of the things they said to us. This kid said something like, “Well, yeah, I used to think that… there [were] such narrow signs.” He thought there were just a few things that mattered, “But then I was doing more research and put more science into our film, and there was like a long list that I found, and I was like, wow… it’s a lot more than I thought it was. And so just knowing all these things off the list is just making me more aware, and I’m checking on my friends more, and making sure they’re okay, you know?”

[00:32:58]
I’ll read this one also because I think it’s really important for teachers that are out there. This teacher says, “I had a student who…said…I’m really worried about this other student. She’s been texting me about her plans to end her life, and I’m trying to figure out how to navigate this correctly because I feel like I have a responsibility to honor the trust she has with me with this private information. But I also know what we’ve talked about…” Since this teacher says I know this case would have transpired differently, she says number one, if we hadn’t had those discussions where the student felt comfortable talking to me about it. So just by talking about it in your classrooms, you’re opening the door for kids to come forward and ask for help. They need more spaces to talk about this. And also, of course, this child learned if I’m your real friend, I have to get help for you, I can’t keep this as a secret.

[00:33:46]
Okay, I won’t read all this because we don’t have time, but they did realize they were less alone. They felt a lot safer going to other kids. And I will read this last one. “Before, it was kind of one of those things [where] no one talks about it, but you know, like those go to the counselor, you know. Like no one actively says like, ‘Hey, if you need help, I’m here.’…But after Directing Change, like I said, we ended up going through advisory periods and showing the film and talking about it, and everyone talked about it in a different way. It wasn’t just like, you know, ‘quiet-hush’ thing…No one was really scared to talk about it, or like say big words like ‘suicide’ anymore…”

[00:34:20]
So, that was a lot. What can you do? I know that’s mostly why you’re here. That was a lot of background and a lot of other ways other people are starting to talk about it. So what can parents, and teachers, and providers do? You can know the warning signs. I’ll talk about that. Ask directly the question, make a safety plan, reduce access to lethal means, connect these children who are struggling to professionals, work trained and suicide prevention, and figure out how to do it in a not a traumatizing way. We do not need to throw every child who’s having thoughts of suicide into inpatient. We need to think about how to do it in the least restrictive way so that we can keep them safe.

[00:34:54]
So these are some of the warning signs, and I’ll read some of these. There’s a longer list on a parent brochure that Directing Change produces. That’s what’s on the right hand side of the slide. Has your child lost interest in things? Are they having dramatic mood changes or changes in behavior? Have you noticed them getting more angry, or irritable, or agitated? So sometimes it’s not sadness. It actually comes out as anger or anxiousness instead. Are they engaging in risky behavior? Are they doing things that are a little riskier than they had done before? Have they started to give their way some belongings? Some of these, maybe not the last one, but many of these are things that look kind of like just normal teenage stuff, right? And that’s what’s so tricky about this, and it’s why, I’ll tell you in a second, like it’s very hard to see the difference between normal teenage angst and suicidal thinking for for many, many, kids.

[00:35:45]
But there are some critical warning signs you do want to pay attention to. If any of these are present, you do want to call 988 or a mental health professional right away. If you have a child talking or writing about death or suicide, if they’re seeking methods for a suicide attempt, including searching online. And if they’re talking about feeling hopeless. Like they say, “I don’t know if it all matters anymore” or saying they have no reason to live, right. This is what these are. The real, real, clues that are very important that we want to move more quickly with, okay?

[00:36:17]
Okay, so what do you do? You’re seeing these signs now. What do you do? The first thing is to find a place to have a conversation. How do you start that conversation? So the first thing is to create the space for it, okay? It’s not about having all the answers. It’s not even having any answers, okay? It’s about sitting with them in their emotional pain. Remember, they feel powerless, they’re in emotional pain. Letting them share that pain with you, with someone else, can actually ease it. It’s like those volunteers, right, in that office, right, with Chad Varah, right? It’s like letting air out of a balloon.

[00:36:51]
So David Brooks wrote this piece, it was back in December of 21. He says, “Rabbi Elliot Kukla once described a woman with a brain injury who would sometimes fall to the floor. People around her would rush immediately get her back on her feet, before she was quite ready. She told Kukla, ‘I think people rushed to help me because they’re so uncomfortable with seeing an adult lying on the floor. But what I really need is someone to get down on the ground with me.’”. And so that’s what I tell parents when they have kids that are struggling. What to do? I tell them to get on the floor with your child who might be in emotional pain. And I know that’s really hard because all you want to do as a parent, or as a teacher, or a doctor, is pick them up and help them, but I’m telling you not to. I’m telling you to actually sit with them in their emotional pain. He ends his piece by saying Kukla pointed out that getting on the floor can be anxiety producing, and when someone’s in deep despair, even dangerous, to the strongest caregiver. It takes a lot out of you emotionally. So sometimes you get on the floor. Sometimes if you can’t get on the floor yourself, like it’s too hard for you to do, you get somebody else to get on the floor with your kid.

[00:37:58]
I love this little cartoon here. It says, “‘Life is like a pot of tea,’ said tiny dragon. ‘Sometimes it’s too much for one person. Share it if you can.’” That’s what we’re trying to do. Just share the pain around, right? These kids have held on to that suicidal thinking for a while. They need a place to share it.

[00:38:18]
Now, how do you ask the direct question? This is the hard part. One of the biggest misconceptions about suicide, I’m sure you’re all thinking this. “Well, wait, the kids are really suggestible and so if I ask them directly aren’t I going to put the idea in a kid’s head?” And the answer is absolutely not. Talking about suicide does not increase suicidal behavior. In fact, by talking openly and directly, you’re sending the message that you care, and that you want to hear them. You’ve actually done the hard work. They’re scared to bring it up to you. I can guarantee that. By you asking the question first, you’ve done all the hard work. You’ve opened the door for the conversation. I call it sort of setting the table for the conversation. You’ve done the hard work and invited them up to the table.

[00:39:00]
Now I’m going to spend another slide on this because I know it’s always your question. Is it really okay to screen for and ask about suicide? So here’s the research on it. Maddie Gould, Columbia University Professor did a wonderful randomized trial. She took a set of kids and randomized them. Half of the kids got a suicide screening tool. Half got another screening tool. She asked both of them about their suicidal thinking and behavior, and had no difference between the two groups. In fact, those kids who were struggling with depression the most, those kids actually had a reduction in depression. So they did see that easing of that emotional pain that I told you about. One of the reasons why I think this is the case for little kids is that: If you’ve ever walked into a—I used to spend a lot of time in preschool centers—preschool center what do you all of a sudden often hear teachers say? Like: “Hey Johnny. I see that you’re really angry, right?”. Why do preschool teachers do that? They do it because they are labeling emotions for kids. It works really well with two-year-olds and three-year-olds and four-year-olds. And we think that if kids can label those emotions, they can do a better job regulating those emotions. So this link between understanding or labeling and regulating, it works for little kids. It also, I think, works for adolescents. And it works for their suicidal thinking. So if we can label it for them, we could talk about it more. It helps them learn to regulate it better.

[00:40:22]
I think the reason why we don’t understand this is because of that wretched history I started this talk with, right, of a crime or a sin. Okay so, now I’ve convinced you it’s okay to ask, but you’re like thinking, “There’s no way I could ask this question,” right? So how do you ask? You actually ask directly. And the reason why you have to ask directly is that given suicide is so hard for researchers and clinicians to predict, the only way to really know if someone’s thinking about suicide is to ask directly about it. And if you can’t do it, especially if you’ve seen those warning signs, find somebody else who can.

[00:40:56]
So how do you ask the question? Well, you can say, “Hey, I’ve noticed that,”—you know, like the kid in the video—“I’ve noticed that you didn’t come to school today. I noticed that you aren’t going out with your friends as much. I noticed that you’ve been really antsy, and I just have to ask are you thinking about suicide?” Or maybe you haven’t seen any of that and you just want to say, “Hey I just heard a talk about how suicidal thinking is really much more common than I thought, and I just have to ask, are you thinking about suicide?” And then once you ask the question, you need to stop talking immediately. I don’t want you to immediately, like, take it back or say like, “Oh I’m sure you don’t feel that way, right?”. You don’t want to shut down the conversation. You want to open the conversation. So you want to look, like, interested and open.

[00:41:42]
Stan Collins, who gives these talks, says you have two ears and one mouth for a reason. So listen more than you speak. And if they say no, you can say, “Okay, but just know that like I’m here if you ever do feel that way, or you know somebody else who is. If you ever do have those thoughts, it’s really important to talk to an adult about it, okay?” And often that’s the first conversation you have with everybody.

[00:42:08]
Now if they say, yes, they say, “Actually I’m really glad you asked. I do feel that.” I don’t want you to freak out. Thinking about suicide does not mean they need to be hospitalized immediately. I want you to picture what you would do if your child came to you with a headache, and you didn’t know whether it was a headache because they needed glasses, and they’ve been reading too much. They hadn’t had enough water that day, and they were dehydrated. Or you needed to bring them into the pediatrician, to actually go eventually see a neurologist. You would ask a set of questions. Even if you’re not a doctor—I know pediatricians might be in the audience—but some of you were not. You would ask a set of questions and you would say, “How much does it hurt?”, right, on a scale of one to ten. You’d say, “How long have you felt this way? When was the last time you felt this way? What happened right before you felt that way? What were you doing? And what happened to make it go away last time?” And what you’re doing and asking these questions is not only opening the door for them to tell you more about it, but also helping them learn the things that they’re already doing, that are working for them, right, that are helping distract them from those thoughts. They’re taking those thoughts out of their head and it’s helping them articulate their coping mechanisms that are already very effective.

[00:43:22]
I don’t want you to, even though this is really scary, and I know it’s super scary. Trust me, if you’re scared to bring it up, your kid is really scared to bring it up with you, okay? I want to acknowledge that this is really scary and the problem is, I’m telling you it’s really scary and you’re not allowed to do anything about it except to listen, okay? You know when your kid, you know, was a toddler, and they fell down and had a broken knee, you know, a cut knee, you could pick him up and hug them and put a Band-Aid on. You could do these things, right? And I’m telling you not to do any of that. It’s really hard to not fix your problem, but I don’t want you to do that. Really good language though, that you can use.

[00:44:00]
Stacey Freedenthal—wonderful clinician and suicide prevention advocate—has some wonderful language on her website called speakingofsuicide.com. She’s got a Blog that says the 10 things you can say to a suicidal person. Like: “I’m so glad you told me that you’re thinking about suicide.” You don’t want to minimize. You don’t want to say, “But you have so much to live for.” Right? That’s making them be like, “Well but I don’t feel that. That doesn’t feel like what I’m feeling right now.” You want to seek understanding. “What’s going on that’s making you feel that way? Tell me more.” Invite conversation. And then you can say, “I hope you’ll keep talking to me about your depression, or anxiety, or thoughts of suicide”. She has a wonderful new book out: Loving Someone with Suicidal Thoughts. Great language in it. I encourage you all to buy it. Really good book to have.

[00:44:46]
You have to make safety a priority. So if somebody’s thinking about suicide, if a child is thinking about suicide, and especially if they have a plan, if they are an imminent risk that they have thoughts and a plan to, act on it. You’ve got to work to keep them safe, okay? It’s really important. And that means understanding what is their preferred method for taking their life, but also taking out those things from their environments that they can hurt themselves with. So that includes weapons, firearms in particular, that they can hurt themselves with. You want to securely store medication. There are lock boxes that are available at local pharmacies. You want to put away both your over-the-counter medications—like Tylenol—but also prescription drugs that you might have gotten for a procedure, and never finish, that are sitting in your medicine cabinet. And this is just the way we would do as if we’re baby proofing our homes. We did all of those things when our kids were babies, right? You want to do all those same things for all teens, and particularly for suicidal teens.

[00:45:54]
You can also to create something called a “safety plan”. Barbara Stanley—wonderful Columbia Professor—developed something called the “Stanley-Brown Safety Plan”. There’s an app you can download, it looks like this on your phone. You can walk your kid through it. Your mental health professionals should be doing it too. It talks about the things that activate the kid, the things they’re already doing that are helping distract them, the people they can go to when they’re in crisis, and it really helps them articulate a bunch of those kinds of things. It’s a great sort of talking tool, and you want to keep revisiting it with them on a regular basis. And then your child can also download a wellness app. So “Virtual Hope Box” allows them to articulate some things that are helpful to them, so they can access that when they’re feeling without that hope. A wonderful app called “notOK” where they can identify a few people. It was made by a brother-sister pair. Identify a few people that they can ask for help. Press the button and immediately those people will be notified, “Hey, please check on me. I need some help.”

[00:46:40]
And then most importantly, a child having thoughts of suicide—especially if they’re having a plan—needs to be evaluated by a mental health professional and somebody with training in suicide prevention. Just like if your child had cancer they’d see an oncologist, not just your pediatrician, in the same way, not all mental health professionals have training and suicide prevention. So you can call a local crisis center, a mental health professional, your family doctor. And you do want to reach them as soon as possible, especially if your child is at risk. You can always reach out to the crisis lifeline or the text line right away. And then finally, please take care of yourself. Take a deep breath, just like they say on the airports, right, in the airlines, right, putting the mask on yourself before you put it on the person next to you. This stuff is hard, and you are a better parent, and a better provider, and a better teacher when you’re calm and you have your own support system in place.

[00:47:33]
There are lots of resources out there for help. 988 is more than just a suicide line. You can actually call if you’re worried about somebody too. So if you’re worried about your kid you can call and ask for help. They’ll put you on hold longer, but they will give you information. Trevor Project has a wonderful set of lines, chat, phone, and text for LGBTQ+ kids in particular. Wonderful website called “suicideispreventable.org” and Loving Someone with Suicidal Thoughts book.

[00:47:59]
Very quickly, I’m going to end because I know we’re just about out of time. This talk is part of a larger “Center” that I named, called “Arcadia For Suicide Prevention”. And I call it that after Frankie of course. It was a play that Frankie read in her senior year called “Arcadia” by Tom Stoppard. A number of themes that I won’t go into that are really relevant to a lot of work in suicide prevention. But I’m going to mention one, which is its title, which comes from this painting which actually alludes to—it’s actually a picture of a country scene, Arcadia—but a tombstone in the middle of it. And the notion is that even in the context of beauty and tranquility, there is tragedy. And I think just like that, we need to acknowledge that suicide is among us, and by doing that, by that acknowledgment, I think we can make a difference in suicide prevention.

[00:48:49]
And I’m going to end with, of course, the Post-its and Frankie’s friends. So I think sometimes we feel like our words and actions are as flimsy as these Post-its on the wall. They’re carefully chosen. I gave you some language but way too few, and especially when we think about all these onslaughts that are really impinging on our kids’ success, and their healing, and their moving forward.

[00:49:14]
Last fall, a year ago a student that was only a freshman when Frankie was a senior asked if they could redo that corner because of course with covid, actually all the Post-its had come off the walls. And this time was permanently, and she made it into, they made it into, this, which is something called the “Love Saloon” instead, now. I’m complete with an affirmation station where you can articulate around your mental health and things that help you. And so, I guess my final message to all of you is to start your kids healing with these simple words and a space to listen, like the Love Vestibule, like Frankie did with her friend in that space. And while it might feel like our words are as flimsy as those little Post-its against all of the things that are happening in this world, trust me that others are going to be really inspired by you, and your modeling, and your example of doing it. You’re going to tell people about it, you’re gonna say how hard that was, but they’ll join you in doing that. And I think if enough people do this, set the table for those conversations, give more spaces for kids to have those open and honest conversation about what’s really scaring them, I think it’s going to be, we’re going to create a world, that’s as sturdy as this Love Saloon in my daughter’s school.

[00:50:30]
So with that, I am going to end. And I look forward to your questions.

[00:50:40]
CHIH-CHING HU: Thank you so much Dr. Morris-Perez for the wonderful talk. So let’s open up to Q&A. Is it okay to say I think we need to get some help?

[00:50:53]
DR. MORRIS-PEREZ: Is it okay to say you need-

[00:50:56]
CHIH-CHING HU: Need to get some help. Is this okay?

[00:50:59]
DR. MORRIS-PEREZ: Absolutely. Absolutely. I mean I think that if you’re talking to a child and they are wondering, you know, and you feel like you can’t do it all yourself, you can say, “Hey I’m here with you. I’m gonna, we’re gonna, figure this out together. We’re gonna get more help together, to really help you move forward, and help you through this.” It is not something that you need to say, “I’m going to do it all myself and all alone”. Absolutely, but I think it’s also about saying that you’re gonna listen to it, and be there by your child’s side. Be their rocks, right? While they’re going through it as well, right?

[00:51:36]
CHIH-CHING HU: Are there cultural considerations to take into account when talking directly about suicide?

[00:51:45]
DR. MORRIS-PEREZ: Other cultural consideration. Yeah. I mean I do think that different cultures speak differently about emotions, about mental illness, and about suicidal thinking. The barriers to approaching mental health treatment can be different across cultural groups. So, absolutely. I do think there’s some commonalities as well, right? In the base, we’re all human as well and asking the question directly is not sort of, doesn’t need to be culturally specific. But yes, our approaches can vary by culture, and it really is important to sort of recognize those differences, and be open to them as well.

[00:52:26]
CHIH-CHING HU: So if someone has received a treatment and no longer considers suicide, how do I tell if a suicidal ideation returns, and what should I do if it does?

[00:52:38]
DR. MORRIS-PEREZ: Great question. Yeah, so one of the things we know about suicide is that it’s not linear, right? So sometimes somebody may feel suicidal thinking for a period of time. It may go up and down over a period of time. It actually could be higher one time of day, and lower another time of day, right? Some people feel it constantly. Some people feel it fleetingly as well. And yes, sometimes it can be relieved by therapeutic services, right, like therapy. And sometimes it relieves on its own through other aspects, other coping mechanisms. I think you still want to look for those same warning signs, the same kinds of things that I was speaking about before. So it doesn’t change the way we’d still look for those even if it’s sort of returning. And again, you want to just continue to open up the conversation and say, “Hey, like I’m so glad you’re feeling better, and if those thoughts ever return, I really hope that you’ll come back to me, and talk to me again about that suicidal thinking.”

[00:53:35]
CHIH-CHING HU: How do you get someone to see a provider when they are resistant, even with depression?

[00:53:41]
DR. MORRIS-PEREZ: Yeah. I mean this is one of the hardest things, right? So like you know we all think that providers have, you know, as a really important part of the answer, you know sometimes kids don’t want to go see a provider. And in part because, right, don’t forget, you know, seeing it’s really different. I mean one thing I think you should explain to a child or to youth is the ways in which a therapist is a really different adult in their life than their parent or teacher. Most adults in their life tell them what to do, right? A therapist does not tell a child what to do. A therapist helps the child learn what they want to do. And so the first thing I would do is sort of talk through that with your child or with this child, to really help them understand the different role a therapist plays than a parent or a teacher, okay? The second thing is in the end you can be like, “Hey can we just try out one, and if you hate it, then we’ll try another one.” Like it has to be a match between the child and the therapist. So it’s also okay to be like, “Can we just try one and see if that works?” You know it’s all about trying to help them feel better in the end. And you can’t force a kid to go, right? It really does have to be their choice in the end, right? But it is about listening, and understanding, and asking them what are the things that are making them scared to go. One thing that might be what they’re really scared of is actually ending up in an inpatient unit, right? They don’t want to talk to a therapist because they’re afraid that if they’re really honest with them, they’re going to get locked up or get something taken away from them. And so the trick is to really help. The therapist is there to really ease their emotional pain and really help them to start to understand that. But you’ve got to find a therapist that they actually can trust as well.

[00:55:29]
CHIH-CHING HU: Is there some medication that helps with the suicidal ideation?

[00:55:34]
DR. MORRIS-PEREZ: So suicide is co-occurring with other mental illnesses: depression, anxiety, PTSD, a number of others. And so many of the same medications that we do for those illnesses are also used for suicidal thinking as well. But they don’t work for everybody. So yes, there are medications that are out there that can help. What they mostly do is they, you know, some of the medications for example, lift the depression. Again, I’m not a clinician so I’m describing what I understand from these, and you really should talk to a psychiatrist to explain these distinctions. But in general, yes, there is medication out there. They sometimes lift the depression enough that actually somebody can start working on the suicidal thinking part of this, right? They don’t necessarily get rid of the suicidal thinking. They actually help you do the behaviors that help reduce the suicidal thinking itself.

[00:56:28]
CHIH-CHING HU: So what more can parents do once they have listened and emphasized?

[00:56:36]
DR. MORRIS-PEREZ: What can they do? I mean, so most important is literally just to listen. I can guarantee you like a lot of just the sitting, and listening, and understanding, and asking more questions about it is just going to give a kid more space to talk about it, okay? That is the most important thing. You want to do it in places where it’s easy to have those conversations. So that could be in your living room, but maybe it’s actually, you want to go for a walk with your child because then you don’t have to be eye to eye, and actually kids might actually say more. Or they’re in the back seat of your car while you’re driving, right? You don’t want to have distractions, right, you don’t want to have your phone with you. But you do want it sometimes. Spaces like walking is a really good one because you’re like, you’re moving your body, right, and sometimes kids reveal a lot more when they’re like out with you walking. So honestly talking is a huge part of this. It’s really about opening the door, and it’s not a one-time thing, right? It’s continuing to open the door. “How are you feeling today? What’s going on?” And then it’s slowly but surely helping your kid engage in the kinds of things that give them back their sense of identity and purpose, right? Which could be, you know, like you know, doing something as an after school program, in a school building, or you know, or the work that, or the school work they’re engaged with. Like what are the things that actually fill them up, right? Spending time with friends. What are the things that help, you know, sort of give them back that sense of hope in the end, and purpose in life? And so it’s really about sort of helping them find those kinds of activities that’ll really be healing and helpful to them.

[00:58:14]
CHIH-CHING HU: Should a child who has a suicide ideation leave school until they are feeling better?

[00:58:21]
DR. MORRIS-PEREZ: So this is a super complicated question actually. And so, you know, I actually have a good example of this. So you know it really depends on the kid, as I will say. Like so for some kids, being in school might be the thing that’s the source of their suicidal ideation. They’re getting bullied in school, they’re struggling in school in terms of academics. So actually, it’s a place that they’re not healing in. For other kids, school can be such a great distraction, right? So don’t forget. So the way I think about suicidal thinking is like, imagine your kid is walking down the street one day and they see a penny on the sidewalk, and they pick it up, and put it in their pocket. And all day long we’ve told them, you can’t tell anybody that that penny is in your pocket, right? What would that kid be thinking about all day long? They’d be thinking about that penny in their pocket, right? So part of this is literally like, by having kids talk about it, it’s not going to perseverate in their heads quite so much. But the other thing is, it’s really, talk to your kid about whether school is a place that helps. Like it’s distracting so it’s going to be really helpful, or it’s a place that actually is, like I said, a source of their pain. I remember I spoke to a family once whose child had been in inpatient and was getting released from inpatient, and the family said the kid wants to go straight back to school. And I can’t believe they want to do that. I’ve taken time off work. This doesn’t make any sense at all. And I said, “You know, I wonder if the kid doesn’t want to be alone with their thoughts.” Right? So if you stay home, then you’re alone with your thoughts and they just keep persevering in your head, maybe the school is a really good distraction right now. And I think that helped right them to see that. So it really depends on the kid, is the way I would describe it. And talk to your kid about whether they feel like that’s helping them or not in terms of their suicidal thinking.

[01:00:19]
CHIH-CHING HU: All right, next question. Is there more suicidal ideation, especially among adolescents than there used to be?

[01:00:27]
DR. MORRIS-PEREZ: Yes, the rates have gone up slightly over the last 10 years. So suicide ideation, thinking about suicide, and suicidal behaviors have increased sort of slowly since 2011. So over the last 10, 12 years. I do also think that we’ve been talking about it more. So I think two things have happened. Yes, I think kids are thinking about it more now than they were 10 years ago. I will say actually rates were really high in the 90s. They came way down and then they’ve been slowly climbing since 2011. So if you look back 30 years, we’ve actually had higher rates in the 90s. But we are talking about it a lot more, so I do think kids are more open about it. I think that’s a good thing. And yes, I do think there is a modest rise as well in suicidal thinking.

[01:01:20]
CHIH-CHING HU: How can parents handle their own stress while living with someone who may attempt to suicide at any moment?

[01:01:29]
DR. MORRIS-PEREZ: So this is the scariest thing, right? So like, you know, listen I’m not going to minimize this. I think for a parent knowing that your child might take their life, it’s like the scariest thing for a parent to hear, right? And I think the best way to take care of that is two things: learn as much as you can, you know, read these books that really help, that you feel like are speaking to you, that are giving you the kind of advice that resonates with you and your family, okay? That feel like they’re respecting you as a family, like Stacey Freedenthal’s work and others, they feel like they’re arming you with the right information ultimately. Do what you can to keep your kids safe, and then you’ve got to take care of yourself. You got to do all the kinds of things that are stress relieving yourself, you know, find a friend to talk to regularly, go for long walks, you know, all of these things to take care of yourself. Because like I said you’re a better parent when you are calmer and when you can sort of manage that level of stress. It is very, very, stressful. I will say, one other thing about this, which is that for most kids, and not everybody, but for many kids. Kids who have a preferred method of taking their life, if you keep them away from that method, that typically can keep them safe. So it doesn’t work for everybody, but it does work for many kids. So, you know, you don’t want to sort of have your mind racing about. Like, well, there’s 20,000 ways that they could do something to hurt themselves. Most kids, like I said, have a preferred way, and that if you can stop sort of access to that preferred way, whether it’s taking pills what have you, it really does reduce the risk of suicide for that child.

[01:03:17]
CHIH-CHING HU: Okay. When a child is hiding their depression behind a smile, how can a parent tell?

[01:03:23]
DR. MORRIS-PEREZ: Yeah, so this is the thing. So some of its hiding, and so two things I want to say. So part of it is, kids hide and can hide. Sometimes also when a kid is with you or with their friends, they’re not as depressed, right? So because this is highly volatile, a kid could feel okay one minute and then the next minute not feel okay, right? So it does change over time. So some of its hiding. That’s what I was talking about, the camouflaging. And some of it’s just highly variable. So like at night, maybe when the kid’s not with you, or not with their friends, they’re feeling more suicidal. So that’s exactly why I say you’ve got to ask the question and you’ve got to be open about it, right? So I say in our family now because we are incredibly open about it after we lost Frankie, it means that other kids are friends of ours talk about suicidal thinking with us really openly. And I will say that’s a really good thing because we are sort of a safe place to talk about it now. We need more people that are comfortable talking about it sort of all over the place. And I think it’s okay to talk about it, you know, with your friends and colleagues too, about like, “Hey my kid’s struggling, you know? What are you doing?” right, and sharing that information.

[01:04:35]
I remember once after I came back to work, after we lost Frankie, somebody had left me a card in my office that said, “Hey, my kid’s struggled with depression for two years in bed, and I came to work every single day and I didn’t tell a single person about it. And then, you know, there’s a pit in my stomach every day. And then I went home and did what I had to do to try to see if I could, you know, help my kid. And I don’t know what happened, but my kid got better and it was nothing, really, that I had done.” But the piece that struck me the most about that letter was that she hadn’t told anybody about it, maybe because she was embarrassed, maybe because she felt like someone would judge her as a parent, maybe they’d judge her kid, rather than sort of getting the support she needed. So I just like I said I think the more we talk about this as a society, the more we’re all going to support each other. When you look at cancer survivors, right, one of the things you get is like people who are struggling with cancer support other people who are struggling with cancer. Like we need more of that in this in mental illness and in suicide prevention as well.

[01:05:46]
CHIH-CHING HU: Okay. What are things we can do for our adolescent children to trust us when they are in pain?

[01:05:54]
DR. MORRIS-PEREZ: Yeah, I think you have to be trustworthy, you know what I mean? I think we want to open the door to the conversation. Kids, you know, listen. I also want to say something that, like, it may not be an issue of trust. It may be because they’re protecting you. I remember hearing once from a kid who said that they had struggled with suicidal thinking. They hadn’t told their parents. They had a great relationship with their parents. They said, “I didn’t want to worry them.” Right? So sometimes why they’re not telling you is not because they don’t trust you, it’s because they love you, because they care deeply about you, and they don’t want to make you worry, and they know there’s a lot on your plate. So I think it’s also about just showing that you can handle it, I think it can make a really big difference too. And then like I said, not freaking out when they, if they do tell you that, they’re struggling or their friend is struggling. Chances are your kid knows somebody who’s struggling if they’re not struggling themselves.

[01:06:55]
CHIH-CHING HU: Are certain diagnosis more likely to result in suicide?

[01:07:00]
DR. MORRIS-PEREZ: So anxiety and depression are sort of the two that like, you know, at the top of the list, for sure. But there’s a bunch of others as well. Like I said, PTSD and other similar diagnoses are related to suicidal thinking. So those are there. I think what worries me, actually, is that everybody assumes it’s only depression. So we’re like, “Oh well if my kid’s getting up and going to school and they’re not depressed,” right? They’re not clinically depressed, right? Multiple days of lying around and not being able to get up, then they must not be suicidal. And I think that’s the challenge, right? That’s not the case. So there are kids who struggle with suicidal thinking that are not depressed. There’re also some who have suicidal thinking and no other underlying, as far as we know, mental illnesses. And so that’s super complicated and hard for us to all understand sometimes. But that can be the case. You can be so suicidal. Like suicidal is just about death and wanting to die, right? Severe emotional pain doesn’t have to sort of reach the clinical diagnosis for depression, or anxiety, or another mental illness.

[01:08:18]
CHIH-CHING HU: If I ask directly about suicidal ideation, how often is too often?

[01:08:24]
DR. MORRIS-PEREZ: Good question. You know, there’s a delicate balance, I am sure. But you don’t want to be asking every day like, “Hi you suicidal? Hi you suicidal?”. That would be too much uh for sure. I think it’s like I said, you don’t want to just ask once, and then never ask again. Like “Oh my God I’m glad we got that over with and we’re never gonna ask it again.” Right? It’s much the same way you have all of those hard conversations with your kids, right? About, you know, about sex, and about drugs, and about alcohol, right? You repeatedly have those conversations over dinner when you talk about drinking in moderation, or whatever. However, you talk about it as a family, whoever you feel comfortable talking about it, those are conversations you want to continue to come back to again. Not every day, but on a sort of regular cadence, so that it feels like it’s something open that you can just bring up on a sort of regular basis. It’s not only once, and it’s not once a year. But it is about opening the door to the conversation. And certainly if you see changes in the child’s behavior.

[01:09:35]
CHIH-CHING HU: Can you develop PTSD from having a friend who died by suicide?

[01:09:43]
DR. MORRIS-PEREZ: So having a friend who died by suicide, I’m actually going to broaden the question. Like I said, I’m not clinically trained. PTSD can be an outgrowth of having a friend who died by suicide. It can also be an outgrowth of other trauma. I will say having a friend that died by suicide, it can be especially challenging. Suicide is a very complicated loss, right? Your family knows this. My family knows this very well. It pairs the grief of loss with shame, and guilt, and responsibility, and all of these other things that sort of layer on, anger, sometimes for some people, layer on other emotions that are really hard to get through. And all of that can sort of challenge even the strongest person. So often people who know people who died by suicide can struggle with all kinds of mental illnesses, and struggle with suicidal thinking themselves. The friends that are most at risk are two groups. When we worry about kids, we worry about the friends that are closest to the child who died. And then we worry about the kids that are farther away, but are struggling with their own mental illnesses before this happened, right? So those are the two groups you want to check on the most after a suicide loss: are the kids, like I said, the close friends, and then these other kids that had underlying mental illnesses. But honestly, like, everybody’s affected by a suicide loss. So that’s why we need more, what I was calling at the beginning, postvention programs as well. Those supports for people after a loss. We know very little about how to do that in schools. We know what not to do, and we have guidelines for that, but we don’t know really how to support kids in, sort of healing, and grieving.

[01:11:34]
Actually, I will provide another resource for those people who have experienced a loss or know a child who has. There’s a wonderful group called “The Dougy Center”. They work in child grief out in Portland. They are amazing. They have all these resources, podcasts, called “grief out loud”, books and resources for kids who are struggling with grief, not just a suicide but their losses as well. Wonderful, wonderful, group.

[01:12:03]
CHIH-CHING HU: All right. And thank you for sharing that information. Next question. How do you tell if a suicidal threat is real or manipulation?

[01:12:12]
DR. MORRIS-PEREZ: Great question. So this is what we often worry about, right, is that people are like, well, are you just being manipulated? So first of all, I will say that there’s a wonderful chapter on this in Stacey Freedenthal’s book about “Is it manipulation?” It might feel like manipulation to you. It may not be intentionally manipulation to the person that’s doing it. So I just want to sort of say that I think you need to take every suicidal, threat so to speak, seriously. You need to treat it as if it is true suffering that somebody is going through. And treat it as that, and not sort of minimize it by assuming that it is a sort of particularly manipulative piece. I will say that sometimes we feel manipulated by it, and, like I said, there’s really good language in Stacey Freedenthal’s book, an entire chapter on this topic. And I sort of really refer you to that as well. But in general, reporting suicidal thoughts is not a manipulative behavior. I think in general, we think that it is about people who really are struggling, and then a huge amount of emotional pain, which, really, you know, and we really need to address that.

[01:13:33]
CHIH-CHING HU: Right. Dr. Morris-Perez, we have another five minutes to go. We have many questions that we can continue.

[01:13:41]
DR. MORRIS-PEREZ: Yes, I’m fine continuing. No problem.

[01:13:43]
CHIH-CHING HU: Thank you so much for staying so long with us.

[01:13:45]
DR. MORRIS-PEREZ: Not at all, no. That’s an important topic.

[01:13:49]
CHIH-CHING HU: Okay so next question is, do teachers have something to do beyond what parents do?

[01:13:55]
DR. MORRIS-PEREZ: Yeah, I think teachers are really important. So you know, listen, sometimes kids don’t wanna, the last person they want to tell is their parents, right, because those are the people they see every day. Like I said, sometimes they’re worried most about them. There’s lots of reasons why they may not tell a parent first. Teachers are hugely important. You see kids so often in the school day, you see the kids in a different environment, you see them interacting with friends, right, and other peers. So you can see things. It’s changes in behavior that a parent may not see at home. And so I think teachers are very important adults around kids that can keep an eye out for things, but sort of, again, open the door to the conversation. It’s why I shared those stories, those quotes, from those teachers. I think they were really, really, important. Sometimes teachers can then connect the child to care in the school building, to a counselor, to, you know, and contact the parents on behalf of the kid. But yeah, really, really, important sort of other adults that care for kids. What kids really need is to know that adults around them care and are willing to sort of, you know, check in on them on a regular basis. And that’s what teachers can really be, really important to do.

[01:15:11]
CHIH-CHING HU: Okay. So is it okay to talk with the fifth and the sixth graders about suicide prevention? Will it give them negative psychological effects?

[01:15:23]
DR. MORRIS-PEREZ: Not at all, actually. So it turns out that kids start understanding the concept of death and suicide, actually, as early as age like, 10, 11. So it’s actually, in my opinion, never too early to start talking about this. I will say it’s, you know, you want to do it developmentally appropriately. So like different kinds of questions or ways to talk about it may come up, but in fact, some of the things we’re really worried about are very young kids who are also have suicidal thinking. It is more rare when you’re younger, but some kids do have suicidal thinking, even at very young ages. There’s wonderful programs, actually, for younger kids. Something called “The Hope Squad”, where kids learn in Middle Schools, how to actually just like, go to a kid who’s like sitting by themselves at a lunch table, and like, be the Hope Squad, right, and go over and just like sit with them, and just like make them feel less alone. So it’s a different kind of program. Different ways to do it than you do in a high school effort, but certainly really important. And it’s very important to talk about emotions more generally with that age group and how to learn how to regulate those emotions as well.

[01:16:30]
CHIH-CHING HU: All right, great! How do we find out about what the preferred method is?

[01:16:40]
DR. MORRIS-PEREZ: Yeah, good question. So what you want to do is, when you’re talking to your child you can say, you know, it was that question like, right, “Are you thinking about suicide?” And then you can say, you know, “Do you have a way that you have thought about taking your life?” And if they say yes, you can say, “Okay, do you want to tell me about that way?” They might describe that way. Maybe it’s a way they’ve looked up online, maybe it’s a way that they’ve heard about through other means. Or maybe they’ve attempted before and they can tell you about that. So you want to ask those kinds of questions, and then see whether you can sort of reduce the access to that way of taking their life. And it’s why, like I said, I think actually most families should be blocking, should be teen proofing their homes, right, given that we still don’t know much about this.

[01:17:42]
CHIH-CHING HU: Okay. So is there any difference between how you help adults compared to adolescents?

[01:17:48]
DR. MORRIS-PEREZ: Great question. Yeah, so one of the weird things is actually the field is very, what I would call, adevelopmental. Actually, we don’t typically differentiate a lot of things for adults and for kids. Many of the adult programs, actually, are ones that actually just have sort of been moved down to younger kids. I will say that, like, it’s partly why I talk so much about involving friends, because I really think that friends and peers play such an important role for adolescents. So that’s a really important piece of the adolescent puzzle for sure. And then there’s also the sort of notion that we think developmentally, right? Kids are trying to develop sort of their own sense of control, right, and, and their sense of, like I said, their identity. They’re trying to figure out who they are. And so sometimes, right, you really want to sort of think about those kinds of issues that would be coming to the floor for an adolescent is different than they would be for an adult who might be struggling with different kinds of issues and sense of responsibility. And responsibility for families, for example, and other kinds of things, right? So this is about: How do we approach kids? But it’s really about just, you know, the same kinds of things we do normally in terms of parenting teens.

[01:18:57]
CHIH-CHING HU: Okay. We’re at about time. Can we have one more question? Last question?

[01:19:02]
DR. MORRIS-PEREZ: Yeah, sure.

[01:19:03]
CHIH-CHING HU: What takeaways would you want us to have?

[01:19:06]
DR. MORRIS-PEREZ: The takeaway is that, I guess I would like to say, don’t be scared of this. I get that it’s scary. Open up the conversation as much as you can, open it up with not just your child, with your child’s friends. And it’s okay to ask about it, and it’s okay to sort of recognize that the sort of part and parcel of many adolescents’ experience. And so the more we’re talking about it, the more we can continue to sort of build those supports and build those protections for our kids. In everywhere, they’re already are. In their homes, and schools, and doctors offices, etc. But also, just thank you so much for inviting me to come and talk about this as well.

[01:19:56]
CHIH-CHING HU: Thank you so much, Dr. Morris-Perez, for sharing your knowledge with us today.

[01:20:01]
DR. MORRIS-PEREZ: Yeah, no problem.

[01:20:03]
CHIH-CHING HU: For the presentation and the Q&A, thank you so much.

[01:20:06]
DR. MORRIS-PEREZ: Yeah, and if anybody has questions after, they’re welcome to email me pamela.morris@nyu.edu. Feel free to reach out.

[01:20:14]
CHIH-CHING HU: All right. Thank you, and thanks to everyone for joining our webinar. And we hope to see you again on April 19th for a webinar with Dr. Jamie Young on the topic about Interpersonal Psychotherapy Adolescent Skills Training. Please take a moment to fill out a short survey. I will leave the donation QR code for a few more minutes, and thank you for donating to support our program. With that, I’m closing the webinar right now. Thank you, goodbye, take care, and stay well.