Restricting Lethal Items & Conducting Body Checks
Full Transcript Below:
Stephanie: Today, we’re going to be talking about minimizing the risk for suicidal behavior and self-harm. So, this isn’t applicable to everybody, obviously. Some of our listeners, are going to find more value in listening to some of our warning-chore consequence podcasts, but this one is for a very specific population. One of the first recommendations that we give parents when their child comes to see us for therapy and we’re doing parent coaching is to minimize their child’s access to lethal items. Now, I say minimize as opposed to get rid of, eliminate, because may things can be lethal and you know you can’t minimize the risk to everything, I mean your child can actually run out into the road and get run over by a car, but you know, what we can remove , we need to be doing so.
Sarah: Right, so some of these items are things such as firearms in the home, which are a super big deal when you’ve got an adolescent that is suicidal in the home, medications, even over the counter medications, locking them up in a safe.
Stephanie: Especially over the counter, a lot of completed suicides are a result of an overdose of over the counter medications such as aspirin, ibuprofen, acetaminophen, or Tylenol. So, we want to make sure that all of those are locked up, and the key is not accessible.
Sarah: Right, and also at times when we have adolescents that struggle with self-harm and cutting themselves we suggest that families lock up knives and scissors and things like that.
Stephanie: Right, and obviously, you wouldn’t want to have straight razors available, and razors for shavings arms, and legs and stuff, need to be removed as well. And that’s a nice natural consequence for adolescents who you know want to maintain smooth legs and underarms, is that they’re not permitted to use a razor unless they go a certain number of days without a self-harm incident, that’s a good natural consequence way of changing that behavior. So, it’s easy for, I mean they can self-harm with many things, I mean they could chew their arm you know. But as much as we can we want to make their preferred method, less accessible.
Sarah: Right, and I think along with that, you know, comes supervision. So if you have an adolescent that is on what we call protocol, meaning eyes on from parents or caregivers at all times, it’s a lot more difficult for an adolescents ad children to self-harm or do anything that is a potential danger when you are within arms-reach of them at all times
Stephanie: Right, and if they’re on eyes on protocol, typically we’re looking at 24, or 48 hours and typically its modified after that. And eyes on, means eyes on, that means…
Sarah: Even when they’re in the bathroom?
Stephanie: Absolutely, even when they’re in the bathroom, meaning no closed doors, no locked doors. I mean you don’t have to sit and stare at them while they’re, you know, taking a shower or going to the bathroom but I mean you do need to have open doors. And, if you’ve got a kid that refuses to keep the door open then you need to remove the hardware from that door and they will not be able to keep it close. I used to recommend taking the door off, but that’s super complicated and it’s actually easier to remove the hardware sometimes.
Sarah: When you say hardware do you mean literally the door handle.
Stephanie: Yes the door handle, like the door knob, yeah the door knob.
Sarah: So that it just swings.
Stephanie: Correct, I can install hardware on a door Sarah.
Sarah: You’re a woman among women.
Stephanie: Thanks, so if we are minimizing lethal items and we’re minimizing risk for elf-harm how will we know that it’s effective. Well when it comes to self-harm we’re going to know that it’s effective by conducting body checks, with minimizing lethal items it’s more difficult because we’ve definitely had the case an adolescent has overdosed on something and the parents weren’t made aware of it until symptoms started to arise, and they confronted the adolescent and asked them. But, don’t hesitate to ask, especially if you see symptoms of lethargy, I mean that’s not the only thing of course. Adolescents are often lethargic, especially in the afternoon of course, but if you see them you know behaving strangely, if they’ve gotten really upset and it’s late at night and they go off by themselves then all of a sudden they’re feeling better. You need to be a little bit suspicious if they have a history of suicide attempts or self-harm. But with our, let’s see. So other signs Sarah, of overdose, they can be agitated, they can throw up.
Sarah: Gosh, I don’t know, sleepy you said already…
Stephanie: Yeah, I mean if you’re missing…
Sarah: I you’re sick, yeah if you’re missing for a long time.
Stephanie: Well no, if you’re missing medication
Sarah: Oh missing medication…
Stephanie: Yeah if you’re missing for a long time…
Sarah: Well I meant like if you’re upstairs for a while and…
Stephanie: Oh I see, yeah, so if the kid is upset and then they go off by themselves somewhere for a long period of time you want to make sure that you’re just doing some periodic checks. And again, this is when your child is at risk.
Sarah: Yes, this isn’t for everybody.
Stephanie: No, so with body checks, and we’re looking for self-harm. They can be awkward, and should be awkward. The family member that conducts the body checks, I mean typically is mom, if it’s not mom and you know there’s only dad in the house, then it can be a grandmother or an aunt, an older sister or something as long as that person is actually beyond 18. But, you want to have somebody that’s going to fully check out somebody from head to toe with underwear on and make sure that there are no new marks. In the beginning we start daily, we want to do daily body checks and then we transition into maybe twice a week, or once a week.
Sarah: So, you know, the accountability from the body checks is sometimes enough to keep adolescents from engaging in self-harm. Especially if they know that there are going to be consequences associated with their behavior. So that is something you’d work with your parent coach to kind of setup what that would look like. But, you know, I do feel like a lot of parents are hesitant to do body checks. It’s kind of like to me, it’s like turning over that rock. And, you know, it’s kind of like out of sight, out of mind type of thing.
Stephanie: You think it’s, when you say turning over that rock, you think they’re afraid of what they’ll find.
Sarah: I do, I do think that. I think there are parents that have suspicions about their child self-harming. But they, you know, choose to look away as opposed to diving in, for fear of damaging their relationship, for fear of breaking trust with their adolescent. For rear of kind of undoing, quote on quote, the progress that they’ve made in therapy thus far. Which, coming from the adolescent side that would have been something that I would have wished the parents would have doing a bit more on the regular when there have been warning signs.
Stephanie: Yeah, so you’ve had adolescents that have said, even though I wouldn’t have liked it, I sure wish my parent would have intervened.
Stephanie: Yeah, my experience with some of the parents that I’ve treated with their not checking on it is, they have felt like, they couldn’t do anything about it. And that checking on it is sort of irrelevant, because they would describe it as, “well this is how my child copes”. And, they feel ill-equipped to do anything, they don’t know how to intervene and so they don’t. So the key here is to have a rule at your house that self-harm and suicide attempts are not permitted. Period. I tell parents, well you know, what’s your rule about your child using drugs, recreational drugs at your house? “Well, we don’t let them do it.” Well, what’s your rule about your child having sex in your house? “Well that’s not permitted.” And so I want to encourage everyone to be sure to keep that mindset when we’re talking about self-harm and suicidal activity – it’s not permitted. It’s not permitted to try to kill yourself, you are not permitted to try to harm yourself, and yes they may do it anyway. The same as they may do drugs in your house anyway, and they may watch television late anyway. All of the rules can be broken, but at least the rule is there. And there’s going to be a group of kids that the rule itself being there is going to keep them from doing it, others are going to at least have some guilt about doing it and therefore, that can help to govern their behavior, it may minimize the likelihood that they’re going to do it. I mean, that’s part of the reason why we don’t run down the street naked, it’s because we feel some sense of shame. So, having that as a feeling that goes along with it can actually be beneficial.
Sarah: And I feel like it’s not a rule if it’s not something that’s expressly forbidden in a family it does kind of normalize it a bit. And suicide and self-harm behaviors are not normal behaviors.
Stephanie: Right, they’re not normative, so I think you’re exactly right. It’s like the elephant in the room, if we don’t say something about it, it just puts us in like the twilight zone. And kids think well this is just the way that it is, well this is not the way that it is. This is something that is a really big deal, and we need to treat it like it’s a really big deal. When we don’t react, we don’t respond, we look the other way, it’s like saying it doesn’t matter. It’s like saying I don’t care. And I realize that some parents, and some therapists for that matter are afraid that attention to the matter is going to make it worse. But I can tell you, and we definitely consider attention as a reinforcer, but that doesn’t mean we just absolutely go to the other end of the spectrum and do nothing. Self-harm is a big deal, suicide acts are a big deal and we’re going to treat it that way. So much so, that if you’re at risk you’re going to need to be eyes on for at least 24 hours, maybe even longer, and we’re going to have to put some serious thought into pulling some of the contributors that might be leading to some of these behaviors such as electronics, such as time with certain friends, such as bedtimes.
Sarah: Such as certain social media outlets.
Stephanie: Yeah, so we’re going to really change over a kids life when this is happening. As we should be.
Sarah: It’s a big deal and we treat it as such. Bottom line.
Sarah: You know, when we were talking about the warning signs of an overdose, I was thinking about what are some of the warning signs for self-harm. Which you know, I think they can sometimes be hard to spot, but they can be things like seeing an adolescent wearing long sleeves in the summer, or refusing to put on a swimsuit and show more skin.
Stephanie: Yeah, or bloody Kleenexes in the wastebasket…
Sarah: Broken pencil sharpeners and disposable razors are another one that parents will often find.
Stephanie: Yeah and then they’re gloomy sometimes, and just generally secretive, quiet, and there’s a group of adolescents that will keep it completely secret, they may self-harm on their legs, their stomach, sometimes they will write things in their skin. And then there are other adolescents that will post it on social media, and I hate to be the one to tell you but it is possible that your kid is posting all over social media, and you have no idea. You know, they’re posting that they’re suicidal, they’re posting that they’re self-harming, they’re posting pictures of all of that. If you do not have access to your child’s electronics, their passwords, their logins, then it is possible that that’s happening. So, also other warning signs would be like blood on the arms of their clothes, you know where it doesn’t belong, so to speak.
Sarah: And there are some kind of creative new ways that adolescents are self-harming, one is referred to as a stick and poke tattoo, which is kind of all the rage nowadays. It’s pretty much like a prison tat where they put ink on the end of a needle and make a tattoo. We consider that at our practice to be self-harm and not allowed. You can get all sorts of scary and yucky diseases and infections from doing that and then it is doing harm to yourself, so we lump that under the category of self-harm.
Stephanie: Right, so the, you know, main thing here is don’t be afraid to intervene when your child is depressed or has a mood disorder and, you know, is self-harming or suicidal. You don’t want to look back and wish that you had done something differently. The relationship maybe impaired but there life can be saved, and if we’re looking in terms of prioritization, what’s more important your child being your friend and liking you or keeping them alive, I mean I would venture to say that most parents, at least decent parents are going to say that they want their kids alive. And, I think it’s just strange that there are some parents that would do nothing to intervene but yet would send their kid to residential. At residential treatment, you want to talk about intervening, they’re going to have to account for everything. They don’t get razors, if they do they check them in and out, if you won’t do it at home, somebody else is going to end up doing it. So you might as well be the one to, because even if you send your kid to residential and they do all that, they come back home and you’re not willing to put in those same parameters when they get into a bad spot, you know a really bad mood state, then they’re going to end right back up there again. And some families will have multiple trips to residential treatment, they get better from residential and get worse again and a huge part of that is because the environment that they’re in is too risky for them. So those locks, I mean real locks, and guns out of the house, razors, you know, no razors allowed. And when a kid is high risk, posts whatever about suicide, they’re on at least 24 hour watch and then you need to be in close contact with your parent coach.