CLINICAL EDITOR’S COMMENTS: The author offers practical and ethical responses to suicidal ideation.
Do Not Ignore and Do Ask Play therapists should not be afraid to ask about suicidal feelings or intentions, particularly when aware of verbal and nonverbal warning signs and risk factors. Death and destruction are common play behaviors for children (Ray, 2011). However, play therapists cannot ignore play behaviors conveying suicide. For example, if a child takes the toy gun and puts it in their mouth and pulls the trigger, the play therapist should set a limit that “guns are not for pointing at people,” and also stop and ask about this play behavior, regardless of theoretical orientation. Risk must be assessed.
Asking directly about suicidal ideation or behaviors has not been found to introduce suicide as a solution; rather, asking may reduce distress therapists cannot ignore statements about suicide, even if it seems this was an expression of anger and not a verbal clue that the child is thinking of killing themselves. Many children can learn the seriousness of saying, “I wish I was dead,” when what they meant was, “I am so overwhelmed and frustrated that I can’t imagine another way to deal with this.” Play therapists must stop and talk about the suicidal statement in the moment.
Empathically Assess for Risk Play therapists are able to validate emotional pain, sit patiently with suffering, and calmly respond to children’s play behaviors and words. This also means play therapists should not overreact to statements or play indicating suicidal ideation. As play therapists help children understand the seriousness of their words, they are allowing children’s emotional pain to take space in the playroom. When faced with these situations in my own playroom, I fully use Landreth’s (2012) “be with” attitudes: I’m here with them, I’m listening, I care, and I want to understand.
attempts. After a child tells me, “I wish I was dead,” I ask if she has thought about what it means to be dead or how she would become dead to gather on her plan. I ask the child what would happen to her if she was dead or if she could do anything else if she was dead to assess her understanding of death and the lethality of her plan. If she has a plan for how she would die, I ask about access to weapons or means. Finally, I ask about prior attempts (which would also mean a higher level of suicide risk), and I explore the dangerousness and timing of these previous attempts, if relevant.
When children are feeling despair and expressing suicidal ideation, it is important to learn more about their risk factors and resources. Play therapists may ask questions about what else is happening in the child’s life to screen for risk factors (e.g., bullying, abuse, other relationship problems) and to explore available supports and resources. Play therapists can empathically assess suicide risk by remaining calm and curious throughout the conversation and open to the child’s perspective.
Provide Hope Clients who are suicidal believe suicide is their only solution to end their suffering. Depending on the age of the child, play therapists may be able to have a conversation about how the child views suicide as a solution. Even for our youngest clients, play therapists convey their care and concern and empathetically state a value for life. Play therapists can help identify and connect children and caregivers with wrap-around services, including referring to crisis lines or to psychiatric care, to provide other solutions and to prevent suicide, thereby rendering their valuing of life actionable. Play therapists should remind children and parents that others in care provides hope as children experience additional support and focus on life.
Create a Safety Plan Safety plans are a best practice in suicide prevention and should be completed in the same session when risk is assessed. Safety plans include warning signs, coping strategies, and resources, including names and numbers of crisis hotlines and adults who can help (Grant & Lusk, based on the client’s interests and resources. For young children, the safety plan may include statements such as, “When I am thinking about killing myself, I will tell my mom,” or “When I have thoughts of suicide, I can color.” Young children may need a version of this plan in picture format with visual cues for coping strategies. The play therapist, child, and family all need a copy of the safety plan, and parents are responsible for removing access to means as a part of this plan. Play therapists will revisit the plan in future sessions, recognizing that coping strategies and resources can change over time.
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