Practical Advice About Youth Suicide Prevention in Primary Care

Audio Episode

About this podcast:

In this episode, you’ll hear a wide ranging conversation about youth suicide prevention with three insightful and engaging experts with different perspectives. This episode is full of practical advice and tips for providers, especially providers working with young people.

About our panel:

Dr. Pedro Centeno is our host, a psychologist, and the educational media lead at SafeSide Prevention.

Dr. Melissa Dundas is a pediatrician and adolescent medicine specialist at NYU Langone Health and the Grossman School of Medicine.

Ms. Kristina Mossgraber is lead lived experience faculty at SafeSide, and the Acting CEO of NAMI Rochester.

Dr. Tony Pisani is a primary care psychologist and suicide prevention researcher at the University of Rochester Center for the Study and Prevention of Suicide, and the founder of SafeSide Prevention.

Show notes/Resources:


Pedro: Hi. I'm Pedro Centeno, psychologist and educational media lead at SafeSide Prevention. SafeSide provides suicide prevention, education, and consultation to health and human services organizations. In this episode, you'll hear a wide-ranging conversation about youth suicide with three insightful and engaging individuals with different perspectives.

Dr. Tony Pisani is a primary care psychologist and suicide prevention researcher at the University of Rochester Center for the Study and Prevention of Suicide and the founder of SafeSide Prevention, Ms. Kristina Mossgraber is the lead Lived Experience faculty at SafeSide and the acting CEO of NAMI Rochester. Dr. Melissa Dundas is a pediatrician and adolescent medicine specialist at NYU Langone Health and the Grossman School of Medicine. This episode is full of practical advice and tips for providers. If you have any questions for any of our guests or would like to pursue suicide prevention education for you or your team, you can find episode notes and contact slash podcast. And now we'll get started.

Tony, could you tell us how you got involved in suicide prevention?

Tony: I got involved in suicide prevention through tragedy, really, when I was directing a family therapy clinic and also working in a primary care center. We had two people die by suicide in the course of three months, and that was very traumatic, of course, for the whole community, the families as well as the people in the centers where I was working. And so I started to learn whatever I could, trying to catch us up on what's best practice, what should we be doing, and how can we better support people. And I started to share what I was learning and then by sharing, I learned more. And that process just continued, learning and sharing, and that continues up to today.

Pedro: Thank you, Tony. Kristina, what got you involved in suicide prevention?

Kristina: What got me involved in suicide prevention was the desire to give back after almost losing my life to suicide. About eight years ago at this point, I almost lost my life. I did not know that I was struggling. I didn't know that I really could have asked for help, and I had so much fear and shame and just all these things a lot of people struggle with.

And then when I started navigating the behavioral health system, I found a lot of challenges. And so once I was stronger and farther along in my recovery, I decided that I wanted to use that experience to give back to people and to be part of the change, and be part of the help, and to use this voice that I have, the voice of lived experience, to say, okay, you can get better.

You can live your best life. Recovery is possible. Your mental illness or your suicidal thoughts or struggles don't define you. They don't make you who you are. And I began volunteering and doing some things, and I was on an advisory committee at our medical center, which is how I met Tony - through that. He had a friend who led that committee and she said, we've got this great program, this great person looking for a lived experience collaborator, and we had lunch and I saw the framework and I said yes! The rest is history as they say. That was pretty great. A pretty great day.

Tony: It was good food too! Awesome.

Pedro: Thank you. Dr. Dundas, how did you become involved in suicide prevention?

Melissa: Thank you so much for having me here. It's been a really interesting journey, to be able to become involved with suicide prevention as a pediatrician and adolescent medicine specialist. Our formal training doesn't encompass suicide prevention and how to ask those questions, how to format visits, and how to support patients and their caregivers.

And so, while I was a fellow at the University of Rochester, Tony had actually found me and we collaborated on a previous project, which actually gave me more education with regards to this area.

Pedro: Fantastic, thank you. Today we're going to be talking about a few major topics here that pertain to suicide prevention, but also as they relate to working with youth and doing all of this work in a healthcare setting as well.

Dr. Dundas, could you tell us what is one of the most important elements when addressing suicide concerns?

Melissa: With youth? Absolutely. I would say the number one thing is to really establish rapport with youth. It might be an area that they're not comfortable speaking about. They have been told not to talk about it, and when they come into our space, we really want to center them and let them know, this is your space, this is your journey. I’m here to listen. And then build that form of trust with them. It just gives them that opportunity to really be able to discuss what's going on.

Tony: Yes, and I think that can be really hard when you're asking these kinds of questions. Melissa, you ask all kinds of questions of youth that are uncomfortable, I'm sure, but they're all uncomfortable in a different way. For this one, I can share some ideas, but I'm just wondering what your thoughts are about how you address this particular topic, how you would typically bring it up, and we can then chime in on our thoughts.

Melissa: Absolutely. So I tend to use what I call a graduation process. So I start off with saying, how are you today? How were you the last couple of days? How have you felt the last couple of weeks? And so it's not this right off the bat asking them, are you having thoughts about wanting to end your life? Are you having suicidal thoughts? Because with teens and youth, that might come off as too much to start off and they may not feel like they can connect with you. So I like to start just very soft with them and then lead into that specific question.

Tony: That's really interesting. I think that's true of adults too, actually. I think it depends on our own comfort, like some providers need more of a ramp-in just to feel comfortable bringing it up. And then some patients need more of a ramp in even when somebody's maybe expressing other kinds of distress or depression.

One phrase I sometimes say is well, how bad has it gotten? And then maybe asking has it ever gotten so bad that you've actually thought about ending your life? Moving into it that way makes the question a pain thermometer question - I’m expressing by the way I'm asking it - I'm telling you I understand that suicide is about things feeling really bad. It isn't just a question I'm asking for me. This is a question I’m asking because I want to know your experience.

Kristina: It's interesting because from my perspective of both working with folks and being a patient or former patient myself, I even think about how with my primary care physician, who got to know me really well, that even when I knew she had to ask about it, I would get anxious. I could feel myself getting anxious, even with the relationship we had, it’s just an uncomfortable topic. Even living in this space, it can be really tough, you know?

Tony: What would make you feel nervous?

Kristina: You know, what's interesting is it's not that way anymore. It's dissipated. I think especially when I was earlier in my recovery I think I felt vulnerable. And when I felt very vulnerable, things felt a little bit scary. And I think I just felt that feeling of, oh gosh, what if I say the wrong thing when she asks? And I think a lot of times, especially with our youth, too, they're worried about what if I say the wrong thing, what's going to happen? Who's going to know? Is this going to get out of my hands?

Tony: Yep. Exactly right. Because we have a system where that's a legitimate concern, right? And sometimes, with good and important reasons, we need to take steps that are increasing the intensity, but there are also times when maybe we didn't need to, but people do move to coercive kinds of things, and getting emergency services involved when maybe that could have been handled another way if the person felt more skilled and confident in being able to understand and respond.

Melissa: That's particularly important with youth as well, because some youth may not understand the true definition of suicide, and so some individuals, if they're having a really tough day, may make comments that allude to that, but that's not actually what they're thinking of doing. And so that's why from my perspective doing that gradual process gives the youth an opportunity to explain truly how they're feeling. So that again, you don't get all of these emergency services involved right there and then that can spook the child. They lose trust in us, never talk to us ever again.

Tony: Yeah, that's a really interesting part, especially with much younger kids. And so what we've been seeing over the past several years is ages of kids that we previously would've said, well, suicide almost never happens. We're starting to see, unfortunately in the youngest cohort of kids, those rates going up. And I actually have a colleague at the University of Rochester, Ariel Sheftal, who is specifically focusing on these younger children, because we know very little about these youngest children, those younger than 12 years old even, who are really expressing these kinds of things. And she's especially focused on black children and youth where there’s even less research. So she's really focused on kind of a doubly important area and it would be useful to probably talk with her at some point like this as well.

Kristina: Yes, definitely.

Tony: But when it comes to asking those questions, we've made a lot of progress in our field in instituting standardized screening, and I think it's hard to talk about connection without talking about how does screening occur and how does it go wrong? Screening is helpful. But if we don't have as part of our routines asking these questions, we're all going to avoid them. What are some of the things that we can think of to make sure that it’s helpful and not harmful? What are your experiences with that?

Kristina: I'll jump in Melissa, if that's okay.. As you're saying that, Tony, all I can think about is having been in an office where someone is clearly reading the questions off the screen or knows them by heart and is just typing them in and there's no response. And I'm like, I'm not sure why you're even asking other than you have to, and when you feel like someone's just asking because they have to you're less likely to be honest and forthcoming because you don't feel a connection and you don't feel that they're actually really listening. It's funny because I'm an adult, clearly, but I also have a mischievous teenage side about me still. And every once in a while, when that used to happen, I would be tempted to give an off-the-wall answer just to see if they'd even look up. I know that's my mischievous kiddo side still. It's funny because for me, I was thinking, I wonder what would happen if I said something silly. Not something to scare them, I was always honest, but it's interesting that sometimes that's what our brain does. I think for me, I was also trying to protect myself.

Tony: It's hard because there are, especially in primary care, there are a thousand times a thousand requirements. We don't know where to put something in public health. The first place we look is in primary care because it's a place where we can access people. And so it's understandable that it goes there but I think sometimes we have to say, okay, in this very long list of things that we have to go through in a flow chart of a medical record, what are the things that can go fast and what are the things that do need that few extra seconds or minutes to talk about, What do you think, Melissa?

Melissa: Yes, definitely. It is more common than we talk about where youth in particular may feel this inclination to not be honest with the first person who asks a set of questions. And typically that ends up being on the individual who may not be the medical person in the clinic. And then they get into our exam room, and then we ask those questions again. And so a lot of us outpatient and primary care providers are striving to educate everybody along that pathway so they learn how to ask those questions. Even your tone of voice can make a huge difference too. And just your body language. Kristina, you had alluded to, if we're sitting there just typing and asking these really sensitive questions, if I was in that position, I probably wouldn't be inclined to answer them honestly too So voice, intonation, intention, body language, all of that really plays into whether or not a child, a teen, a youth, is going to feel really forthcoming in that measure.

Tony: Yes. And one way, while keeping the pace that really needs to happen, one way to convey, let's say a nurse is rooming a patient within a healthcare setting, one way to do that is to add a short preface to the question saying something like our whole team cares about your whole health, and I want to ask you something because we really want to understand your experiences. So I'm going to ask you a couple of questions that may be sensitive, but we really want to know. And then go into it.

Now, I don't know. I didn't check the time on that - it's probably 10 or 15 extra seconds and that's not nothing when you have a lot of things to cover. But I think as a healthcare system we have to decide might that be worth those extra seconds even if we only get 10% or 15% more openness? I think the cost-benefit of an extra sentence or two might pay off.

Melissa: 100%. I would even go as far as saying that could be lifesaving, which is the goal of all of this.

Kristina: Oh, absolutely. Just to reflect on that, it sounds a lot better than “I have to ask you these questions”. With the one more sentence you added it just sounds so much more inviting and caring and genuine.

Tony: Pedro, could you pull up the clip that we have of the nurse Kayla in a primary care telehealth setting, asking this question and bringing it up?

Video clip:

Narrator: a nurse in a primary care practice is talking with Ms. Calderone, who scheduled a telehealth appointment, as a follow-up from a previous visit. In this practice, all patients are screened for a variety of physical and mental health concerns including for suicide risk.

Kayla has already asked some of those questions and is getting ready to ask Ms. Calderone about suicide. Knowing that these are sensitive questions, Kayla has asked Ms. Calderone if she has privacy to answer those questions and to let her know if that changes. Watch for how Kayla asks, with the goal of connecting and better understanding Ms. Calderone's experiences.

Kayla: I'm glad your sinuses are better, but I'm sorry you haven't been able to sleep. I'll make a note to the doctor. We care about every aspect of your health, including your emotional health. Are you okay if I ask you some questions?

Ms. Calderone: Okay.

Kayla: So the first question is, in the past few weeks have you wished you were dead?

Tony: We can stop there. So a couple of things there, right? One thing we didn't talk about before was asking if the person's in a private place, in a telehealth setting. That's really key. And then also asking permission.

Kristina: Yes, that's exactly what I noticed too.

Tony: Now of course the first objection you're going to hear is, well, what if she says no? I think sometimes we've been so trained to think a certain way about information that we forget that the validity of the information actually matters, not just getting it. Because if she says no, first of all, that's important information and that can be followed up on by itself - she was not willing to answer these questions about suicide. Okay. That tells us something and we already know more than we would have if we just asked questions and she didn’t feel like answering.

But also, If somebody's telling you no, then if you had asked them they probably weren't going to tell you the truth. We have to remember that the point of asking is to get data, and it's only good to get data if it's good data. And so that's pretty key and keeping the connection is important for connection itself. Also, like you said before Melissa, it's also important for getting valid and reliable information.

Melissa: I just love that - ask for an invitation into that patient's space. So it goes along with asking permission. Can I ask these questions? Youth are very susceptible to that too. They have their own confines, they have their own space that they protect too. And so asking them for that invitation is just as important in pediatric care as it is in adult care, as we saw in that video,

Tony: I think one more thing that we can say about this kind of connection, that Pedro asked about and that we've been talking about, is if we remember that when we use the word assessment in the context of suicide, for assessment you could almost find and replace that word with the word understanding. So if I say I want to assess, I say I want to understand a person's experience, not assess for a set of thoughts. And if we change it like that, and we talk like that, we can say there's a set of questions I'd like to ask you to help me understand. People want to be understood. Not everybody wants to be assessed.

Kristina: That's 100% right.

Tony: And they probably really don't want to be risk assessed:

“I’m going to assess your risk now”

“Ooh, is this going to hurt?

But most people - if you say you want to understand them – they’ll be up for that

Kristina: For sure. I use the phrase “help me understand”. I can't tell you how many times a day in so many ways.

Tony: You mean in your professional space too?

Kristina: Yes. If you think about it, to your point. people want to be understood and it's amazing how much more genuine, accurate information you can get when instead of perhaps going into a space of judgment or into a space of reactivity, maybe you just lead with “help me understand” or “tell me more about that”.

Tony: So it's something that's probably a generally good skill. And then it's critical when it comes to something that people really don't want to say. And this can be one of those things.

Pedro: Thinking about asking those questions and really trying to understand the person, this naturally takes us to a place of “well, if the person says yes, then what do we do?” So we're faced with providing a response to that concern. Tony, what are some good ways to respond that you’ve found are really helpful when suicide concerns are present?

Tony: I think we want to talk about setting as that will make a difference. Our context, talking with you here, Melissa, is in primary care, or at least healthcare. In your case, you work mostly in adolescent medicine, but I know you've done a lot of work in primary pediatrics as well. I think the first thing to say about what to do is, is to remember that the set of options is more than a mental health referral. A lot of times primary care professionals have been referred to as gatekeepers, they're a gatekeeper to a mental health referral. Now, first of all, you don't want to be a gatekeeper, you want to be a gate opener, right? Gatekeeper would make it seem like your whole role is to identify and refer. Now a referral is important. But it's not the only helpful and potentially life-affirming thing that a primary care professional can do.

Melissa: No, absolutely. And we have to remember that not all areas have access to mental health providers and referral resources. And so in primary care, oftentimes we are the first stop for somebody. And so when we think about what those next stops are, when an individual does endorse suicidal thoughts and wanting to harm themselves, the first question we ask is “well, how do you feel right now? Do you feel safe in this moment?”

The second thing we try to do in pediatrics is ask the child “who do you feel safe talking to?” Thank you for involving me. But whoever you live with, is there somebody at home that you feel comfortable talking to them about this? And then the next piece is letting them know that because they are a minor, you do have to share this information with the person that loves you so much at home. How do you want to do this? How do you want us to share that information? And I use the term us so that kids don't feel alone in that process. And then once we invite whoever that loving human being is at their home, we talk about “can you keep them safe at home right now? What supports do you feel like you need?” and then “I will help connect you to those resources”. And so it's not just a matter of us as the provider saying “Okay, you've told me this. Now I'm going to open the gate and tell you where to go.”

We want to communicate “Let me understand you, not just as the individual human you are, but as the context and the group and the home that you reside within” and what does the whole context of that living situation need and figuring out what to do next.

Tony: For some people where the home is not as safe of a place, there are other people in the community, schools, teachers, and we can expand what we offer by supports. And you mentioned not everywhere has access and availability to mental health. That's true. But even where there is access and availability it can be really hard.

Many people don't want to go. And if they do, it's often for a short time. And so we can't have our entire strategy for suicide prevention, when somebody presents in primary care, rely on that because first of all, there's probably never going to be enough behavioral health professionals to serve every single community, but even if there was, people are usually in care for a pretty short time, but they remain in primary care. So they've gone, and hopefully, we as behavioral health providers have done our job, right – that is, we've communicated back to primary care, and we're working in close collaborations in some cases. And more and more there's actual co-location and integration, especially in more urban or metropolitan areas. That close collaboration is great, but usually that will be for a short time.

So what can do? First, referring and also knowing where to refer - where it's available - there are more evidence-based suicide-specific treatments than we've ever had, and maybe in a different conversation we can go into more depth about those, but second, there are things that you can say and do that provide that support. I think some of the things that you just shared are what you were just doing, speaking in a very collaborative way. Another one can be to help the young person make sense of suicidal thoughts. Not everybody knows that it's not that uncommon to have those thoughts, and it doesn't mean you have to act on them. It's an important signal for us to listen to because it means that things are really bad, things are really hurting, but it doesn't mean that you have to do that or that you will do that, and we're going to do whatever we can as a team to help you not just not kill yourself, but we're going to do everything we can as a team so you don't feel like you want to do that.

So one thing is to help make sense of that, to understand that it’s normal, but I think another is to offer the possibility that things can actually get better. We have quite a bit of research to say that if people engage, especially young people, if they engage with our teams and the kind of supports that we have, which can include a whole panoply of different kinds of treatments and interventions, and give it time, and engage with it, and with adults that they know, they can feel better. And I can tell you many examples of that from my own life and practice, and I can also show you a lot of research that shows people do get better, but we don't always let kids know that.

You’ve got to be careful because we don't want to say something that just feels totally impossible to somebody sometimes. But I think sometimes we're so concerned about over-promising that we don't show any hope.

Kristina: I think it's interesting to hear you to say that, and every time I hear people say that it’s not uncommon for people to have thoughts of suicide, especially when they're struggling, their brain is in so much pain, and when I share that with people, I often get the response of “wait, what?” It's often surprising for people. I mean, it helps normalize the conversation when I’m having it with someone.

Tony: Because they’re feeling they’ve been alone in it? They’re thinking it's just them?

Kristina: Exactly. They've been alone in it thinking it's just them and then thinking if they talked about it, immediately there would be a transport, there'd be intervention, there'd be EMS involved and it would escalate to a pretty traumatic situation. But just to let them know when you hear everything going on in their life, it's not uncommon to have those thoughts, but it's an indicator to us that it's time to dig a little deeper and understand what might be going on, and start feeling better.

Tony: And then I think in addition to saying those helpful things, normalizing, helping people put into context, offering some hope, those kinds of things there are also plans that we can make and that don't take a behavioral health specialist to do, like making plans for a person's safety. There are different levels of doing that. There is an evidence-based intervention called the safety planning intervention that has several steps to it, including following up on these plans, helping a person identify their warning signs, things they can do to distract themselves, and people they can go to. Sometimes in a primary care setting, and certainly in an emergency department setting, it can be challenging to do all of these steps due to time. We want to aim toward that. And it might be that you have to say “we can just get started on this today, but I'd like you to come back on Tuesday and keep going with this.”.

There are a couple of things that I would say to do, even if you can't go through an entire safety planning process, or maybe you don't yet have all of the training and skills or personnel to do that. Let me ask you, Melissa, what's your practice in your setting, and then I can share what suggestions I have. If you could just do two things, what would they be?

Melissa: Absolutely. So I can approach this from two very different points of view. One is having at one point in my life worked in a community hospital where we would schedule close follow up and do some of those smaller portions to keep somebody safe, versus being at an academic center where I do have access to social work in my clinic, I do have access to a psychologist who can be readily available once that assessment, that humanism, that rapport has been built, to help coordinate what those next steps could be. But initially what I would do if I had a youth or a teenager in front of me is that I would just understand the degree of safety concerns in that moment. Do they have access to our clinic numbers so they can call us even after hours if they're going through a period of distress? Do they have access to other national phone lines and do they have the ability to come back in a couple of days for a quick check-in?

So I think those two things are the simplest things that we can do that are actually really lifesaving in that moment. If we don't have extra things that we can provide them with.

Tony: I love that. I guess what I might add to that is addressing means safety and trying to find out what are one or two things that could happen in the person's life that could really send them for a loop. So in our framework we call those foreseeable changes. The idea behind foreseeable changes is that before the person leaves, I really would like to know maybe from the young person, from a family member, what are a couple of things that if they happened, you would think “oh no, I am really worried about my daughter” or just “oh no”. Finding out what those couple of “oh no” things are can let you take the conversation to the next level. How likely is it those things are going to happen between now and when you're going to be coming back? Is this something that's likely or unlikely? Would we know if it happened or would we not?

Those are the kinds of things that can now get us into very concrete conversation and planning, so it's not just “what's a sign that you would know you were feeling bad?“ Well that’s good to do, but that’s more general. This is really nitty gritty, it’s something that could happen, that could really throw you off. And once you know that about a person, you can then begin to inquire about how predictable, how much visibility, how likely, and how soon is it going to happen.

And then I think the other thing I would do, in addition to identifying those foreseeable changes, as we call them, is addressing means safety. What that refers to is to the extent that we can, trying to put distance between the person and the means that they might use to kill themselves. And the way I think about that is I'm looking in two places. One, any means that this person has specifically mentioned before, and then two, any that are more common for that particular age group or culture. So I might think about those two things in terms of addressing those, because I would say of all the different public health interventions that we've had in suicide prevention, reducing access to the means when somebody is in the heat of that kind of suicidal crisis, putting some distance between them and those means is probably the most effective one. And we can't talk about that without talking about firearm safety. Pediatricians have really led the way in this, which really means figuring out how can we keep firearms in a safe location if you have them in your home. And assume that the first two ways you would think of, the young person has already figured out. And then go from there. This is not to say anything about firearms in the home or any of that, it's just that we know statistically that having firearms in the home can make a suicide more likely. So if you have a young person at risk, that's a really dangerous combination so you just want to think it through.

I was just mentioning different age groups and cultures, and that might be a final really important topic. I know we only have a bit more time together today, Melissa and Kristina, so I wonder if we should talk a little bit about that. It's an incredibly important topic, about how we address these concerns in a variety of different cultures. Of course we can't cover every possible cultural group today, but maybe just some that we work with. What are the things that sometimes need to be adjusted and how do we work with family members from different cultures?

Melissa, I know that you're there in New York City. And here in Rochester, we've got plenty of diversity as well. But you're really in the heart of migration, immigration, and all kinds of different melding of culture. So I wonder what your experiences are in that regard.

Melissa: Definitely. I do want to say that it is actually such a privilege to be amongst so many different cultures because that helps really educate clinicians in terms of how to just be even more generalizable and be able to connect with a multitude of different individuals from different backgrounds. But I would say from experience, the most important part is to understand what somebody else's understanding of suicide and mental health is. I never want to assume that somebody who has recently immigrated here for whatever reason, that we share the same understanding or the same context of what that means. And so again, that's like another invitation to say, hey, can we talk about this?

The next part that we really try to do is to de-stigmatize it. I can say in my Caribbean culture, it's still very taboo to talk about suicide and mental health. So it’s saying to the person that it's something that everybody from all shapes, sizes, gender, sexualities, races, and experiences, how can I help you feel comfortable in this space so that we can talk about it together? And there's no judgment here. But you have to approach it knowing you can't paint everybody with the same brush, and once you can actually put yourself into that position, then it's actually quite - I wouldn't say easy - but it opens up that conversation to speak with individuals cross-culturally and to be able to treat everybody with the same standard of care.

Tony: You mentioned not to assume that you have the same understanding. Probably true even within the same culture, but it's especially true across cultures. I was wondering, in your experience, what are a couple of areas where you've noticed there is that difference or disconnect?

Melissa: Absolutely. So an individual's perceptions of struggle is where I've often encountered differences. Let's say I'm working with a family that may have been born and raised in the United States. They're from an affluent community. The child has everything they could possibly want, and the parents are thinking, well, my child can't possibly be having these thoughts or can't possibly be suicidal because they have everything under the sun. And it's navigating that discourse and saying, well, sure, everybody can have all of these superficial things, but there's a disconnect somewhere for your child where they are suffering and it's okay to acknowledge that.

And then there are other situations where, with some of our migrant families who have really seen a lot more than any of us may see in our lifetime, they may see that as the ultimate struggle, not necessarily the mental health component that either was there before or during the struggle, or has resulted because of what they've gone through. And so it's really showing that irrespective of what your background is, folks can still be struggling with suicidal thoughts regardless of those differences in perceptions of struggle. So it's how do we bridge that to say actually, at the end of the day, those things don't matter. It's the individual person and their own internal struggle that we have to center in those conversations.

Tony: That actually makes me think of another kind of reaction that people sometimes have, especially in very close-knit families where the reciprocal ties and bonds are very important. I would actually even say that in my own kind of Italian American family that's true. And it's probably true in others as well. But I find myself sometimes having that same reaction if somebody in my extended family is struggling. My first thought is, well, how could they do that to their parents? Or how could they do that to their sisters? And here I am, I'm supposed to be the psychologist, I'm so open, yeah, great. But within the context of my own family. I sometimes have that kind of reaction, like, how could you say that? So I have a lot of sympathy I guess, or empathy, and identity or resonance, when a parent's first reaction is, how could you think that?

I get that. And we have to work with it. There’s also another part of me that cringes because I know that it’s going to totally shut the young person down. But I also really understand it and I think that it is a key to working with parents and families because I think sometimes those of us who work with children and youth, we do that because we really like them. And sometimes I have seen in some settings where it can get to this place where the kid is the hero and the family's the villain. I think it's really important to avoid that, and the way you spoke before really avoids that. And I think that can be really key to just realizing it's not that easy, it's pretty hard to be a parent. We have a member of our team who is a family carer. She's cared for her brother for a couple of decades who had lots of suicide, mental health, and substance use concerns. And it's really hard.

If we go into those interactions bringing that perspective, then even though probably in pediatrics or child psychology we tend to be on the side of the kid - that's why we love this - just making really sure that we don't even in our minds tend to pit one against the other, and realize that adults, at least in general, are more likely to be supports. Even if they're not perfect, even if they say things like I still do, they can still be a valuable resource.

Melissa: Definitely. And I think to your point there, Tony, we're all human at the end of the day, right? And that's why we're lifelong learners. And as long as we recognize that we can have tendencies like that, we can act on them. One thing I have particularly found helpful with parents in that situation where some parents will be wondering “why is my child doing this to me?” It's gently reminding folks that the child isn't choosing this and isn't choosing to feel this way.

This isn't a choice, right? And at the end of the day, no toddler –well toddlers can be savage at times- but no toddler, child, adolescent, youth, or young adult wants to upset their parents. No one, no child, wants to deliberately disappoint their parents. And I think when parents hear that, they really understand, okay, my child is suffering. This has nothing to do with me. Let me recenter this on my kid and get them the help that they need. And I think just helping reframe that helps the parent understand that this isn't a choice. This is no different than diabetes or cancer or any other really terrible medical condition. We have to treat this the same way.

Kristina: I just wanted to reflect on what you just said, Melissa, what you'd been saying. Tony. I've spent a lot of time working with kids in the schools and we would go through the warning signs, what to do, and definitely, there'd be a young person who would say, okay, I heard what you said. I tried talking to my parent or my guardian, and they said it's just teenage stuff. You're just making it up. You're manipulative. People ask me all the time, do people talk about suicide as a cry for attention or cry for help. And I say yes - because they need help. Because they're hurting. And so I just really appreciate what both of you were saying, but just looking at it through the lens of our young people especially, they don't always have the language and the tools and the understanding to verbalize what it is they need when they're struggling. So sometimes these actions or behaviors can sometimes be dismissed and misconstrued as behavioral or as being manipulative or this and that, it’s really just that we're humans.

Tony: I think that brings us full circle to why a primary care professional is not just a gatekeeper. Because it doesn't take a mental health professional to listen, understand, and you can provide people with a different experience and that's not nothing. It might feel like something like, “what can I offer? I'm not trained in this. What can I offer?” Well we all have a lot to offer.

And I think that's an important note to end on, that people across the healthcare spectrum have a lot to offer. More than just identifying and referring. There are things that we can do and say, and ways to listen, that can really make a difference.

Thank you Melissa and Kristina for having this conversation, it’s been great and really enriching. I've learned a lot from this. And Pedro, thank you for hosting us.

Pedro: Thank you, Tony, Melissa, Kristina. I've learned so much and it's been a really helpful conversation.

Pedro: If you’re listening and would like more information, be sure to visit and you'll find information there about the SafeSide programs and particularly those that are designed for primary care. So be in touch with us through our website!

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