Suicide Prevention Awareness Month: A conversation with a child and adolescent psychologist

September is Suicide Prevention Awareness Month, during which mental health providers, organizations and others share resources and information to raise awareness about suicide prevention. Suicide is the 2nd leading cause of death among people aged 10–34 and the 10th leading cause of death overall in the U.S.

In recognition of this important month, we are featuring Allison Ventura, PhD, a child and adolescent psychologist at UF Health Psychiatry – San Jose. Dr. Ventura discusses her background supporting teens and young adults and strategies for preventing acts of self-harm and suicide.

Question: Tell us about your background and expertise.

Answer: I am a clinical psychologist, specializing in child and adolescent psychology, and am a nationally Linehan-certified dialectical behavior therapist. Dialectical behavior therapy, or DBT, is an evidence-based, gold standard treatment for pervasive emotion dysregulation. I mainly support teenagers, ages 14 to 17, and young adults, ages 18 to 24. Currently, there are only 11 nationally certified DBT specialists in the state of Florida, yet an overwhelming amount of youth are in need of this type of therapy.

In 2017, I received a grant from the city of Jacksonville to help train five therapists to receive DBT-intensive training, which most therapists do not have access to. UF Health Jacksonville has been wonderful in supporting my initiative to provide supervision and training for therapists who want to help this population.

In addition to training therapists in the community, I’m also helping local hospitals learn how to incorporate DBT into their adolescent inpatient units.

Q: What is pervasive emotion dysregulation disorder?

A: Pervasive emotion dysregulation occurs when someone has very chronic, intense emotions that causes behavioral disturbances such as impulsivity, self-harm, suicidal behaviors or relationship discord. These intense emotions are dysregulating the person’s system.

Many individuals are innately born with the biology that makes them more emotionally intense and reactive. However, that alone is not enough to cause dysregulation. The social piece is what kicks in. The main component of the social piece is invalidation.

Invalidation can be very subtle. For instance, when someone who is already biologically sensitive feels an emotion, and another person tells them to stop crying and tries to tell them it didn’t happen that way, their initial emotions are invalidated.

Invalidation can also occur in children who experience bullying. It is very invalidating to be picked on, or to be a target of your peers. Being a victim of bullying is hard, especially for teenagers, because one of the most important things is their peer group.

Invalidation can also be intentional, such as abuse or trauma. Emotions are being abused when someone is invalidating our body and safety.

When biological and social pieces meet, it may cause dysregulation.

Q: What are common forms of self-harm in teens?

A: The most common form of self-harm we see with teens is cutting. Teenagers will use objects to cut themselves, and usually, it’s on their wrists. They also can cut their sides or stomach, because they can hide that more easily. Teenagers also engage in burning and scratching behaviors. Some kids might punch themselves or hit themselves with objects.

Q: Why do teens participate in self-harm?

A: Scientifically, self-harm is a regulating mechanism. When emotions are real, intense and long-lasting, which they often are for this population, self-harm tends to induce soothing feelings. Research has shown that self-harm releases endorphins. There is some kind of pleasure and relief that comes from it. The relief may only last a couple of seconds to a couple of minutes.

Some kids can become emotionally numb, by going from one extreme to the other, such as feeling too intensely, or shutting down and feeling nothing. Teens may get so tired of feeling numb all the time, so they engage in self-harm, because it will activate an intense sensation, regulating the body and becoming an addictive habit.

Q: Besides seeing cuts or burns, what other signs can parents, caregivers and friends look for to recognize self-harm?

A: The problem is that teenagers are just naturally good at hiding things. They can be very clever, and sometimes parents will not be able to discover this until the self-harm has already happened.

Self-harm can often be hidden, especially if it’s in an area where parents don’t normally look, such as the sides of a torso or on the stomach.

We ask parents to observe changes associated with their child’s mood and behaviors, like signs of withdrawal or isolation, or if they’re no longer hanging out with friends. Other signs can be when they’re not engaging in conversation, sleeping more, eating less or eating more.

Q: What should parents, caregivers and friends do when they see signs of self-harm?

A: I encourage parents not to overreact, which is hard. When they see their child performing self-harm, many parents will resort to crying, screaming, punishing or questioning. We also recommend against underreacting, or treating it like it’s not a big deal.

Parents should try to stay calm when they talk to their teenager. You want to have your teenager know you can address what’s going on in a cool, calm and collected way. You also want to be open with your child.

Next, parents should listen. I always ask parents, are you lecturing or are you listening? And listening is just hearing about what’s going on with your kid. How is your child feeling? Listen, then validate the feeling and the situation that happened.

This doesn’t mean that parents are agreeing with the self-harm, but they’re acknowledging the teenager is going through something emotional and stressful.

After parents listen and validate their child’s emotions, they need to seek professional help. Kids with dysregulation disorder need help because self-harm is one of the highest predictors of someone considering suicide.

You want to make sure your teen has a therapist and a physician that can help them address emotions and behavior and determine coping strategies that are more helpful than self-harm.

Q: Can self-harm lead to suicidal behaviors?

A: Both self-harm — clinically recognized as non-suicidal self-injury, or NSSI — and suicidality indicate underlying distress within youth. It is important to assess whether a self-injurious teen is also suicidal. While self-harm does not directly cause suicidal thinking and actions, there is evidence that self-harm is a powerful risk factor that predicts future suicidal behavior more than any other risk factor identified. As you can see, it’s very tricky to tease the two apart, and that’s why families need the help of experienced providers for the evaluation and treatment of their teens.

Q: Do you have a recent patient story you could share?

A: I had a young teenage patient at a local high school who was hospitalized multiple times for suicide attempts, where one attempt involved overdosing. She went through three years of intense therapy with me. This type of therapy can sometimes be long-term, but it works.

Her mom and I would sometimes just look at each other and say we have to prepare ourselves, because her teen could die. It was very scary.

Slowly but surely, this teenager started getting healthier and more regulated. She became involved in the drama group at her high school, and then became president of the drama club. Eventually, she ended up applying for college, and now she’s at a major university and wants to become a psychiatric nurse practitioner.

If you or a loved one are considering self-harm or suicide, know that help exists. Visit UFHealthJax.org/psychiatry or call 904-383-1038 for more information about services offered.

Various helplines are also available to all in case of emergency or if immediate assistance is needed 24/7:

• Disaster Distress Hotline: Call 1-800-985-5990 or text TalkWithUs to 66746
• The online Lifeline Crisis Chat is a free, confidential chat service that connects you to a skilled counselor
• National Suicide Prevention Hotline: Call 1-800-273-TALK (8255)
• Substance Abuse and Mental Health Services Administration, or SAMHSA: Searches for mental health providers or treatment options in your area.