Risk in therapy can, and does, arise in a variety of ways. This post will discuss some of the common ways that risk might show up, and the different ways this might be managed in a private therapy setting. As always, if you are immediately concerned for your child’s safety, or the safety of someone else in your home please contact 111.
As a general rule, unmanaged risk can derail the therapy process. When life is actively chaotic, scary and dangerous there can very little room to think, process, reflect, imagine, play and work through – the essential ingredients of a therapeutic mindset. As a response to risk, families and young people may find themselves in emergency mode, resulting in a combination of fight, flight or freeze responses. When stuck in this state, it can become near impossible to progress, until the external harms are more effectively managed. During periods of active risk, the most important focus becomes harm reduction and risk management. Once a reasonably safe and secure base has been established, the therapy work can begin or resume.
For the purposes of this blog post, therapy interrupting risk might be termed severe risk. Severe risk might include active family violence, active sexual abuse, drug use in the home, suicide attempts, severe emotional dysregulation, life threatening self-harm, acute psychiatric deterioration, medical instability, absconding from sessions or unmanageable violence towards the therapist.
However, mild to moderate risk can also present, and poses a different set of challenges in terms of how this impacts the therapy work. The ways in which this might happen, as well as the ways this might be managed, are discussed in more depth below
Non-suicidal self injury (NSSI) and deliberate self harm (DSH)
Self harm is an unfortunately common occurrence for adolescents. It can also present in younger children. Self harm can take a number of forms and ranges in its severity. NSSI and DSH are abbreviations which both describe forms of self harm which are not actively life threatening though indicate a level of difficulty coping with overwhelming emotions. Common forms of NSSI include cutting, scratching, head banging, burning, restrictive eating, compulsive exercise and hair pulling. Young people utilise a variety of tools for self harm, depending upon what is accessible within the home. Self harm is often a secretive, private activity that takes place as an attempt to manage distressing feelings. Self harm does not always indicate suicidal ideation, however there is often a link between the two.
In the event that self harm is disclosed within therapy, the young person will be informed that their parents need to know what is going on. Many young people wish to keep this hidden from their parents, however this is a non-negotiable discussion. The therapist will work with the young person to understand why their parents or other safe adult must be told about this. Generally, young people are apprehensive but understanding about this fact when informed.
The discussion between the therapist and parents will centre around how to ensure the home environment is as safe as possible, and how to support the young person to utilise alternate coping strategies to manage big feelings. Most commonly, self harm can take some time to cease completely.
Pointers for parents
- Safeguarding the home is an important first line preventative measure. This ensures that the young person has less easy access to things that they might use to harm themselves. Although this doesn’t solve the issue, it sends an important strong message that the family takes self harm seriously, and are willing to step in protectively.
Where possible, it is preferable to safeguard the home alongside your child if they feel on board with limiting self harm. They may be willing to hand over items they have been using to hurt themselves. For some young people, it can come as a relief to have their parents insist on this.
When the child is unwilling, it may involve doing a thorough sweep of the young persons room without them present. CASA have some helpful guidelines for the kinds of things to be mindful of around the home. If locking these items away is not an option, the boot of the car can be a safe place to store things short term. https://www.casa.org.nz/resources/13-guidelines-for-providing-a-safe-home/file
- Parents managing their own responses to the young person’s self harm is another helpful step. Often, young people are afraid their parents may become angry, horrified, shaming, stressed or overwhelmed when they learn about this behaviour. These kinds of reactions are understandable, though can compound the young persons distress and guilt. It is important to balance your worry with with a presence that lets your child know you are bigger, stronger and wiser. This can convey to your child that you are able to help them through this, and strong enough to withstand what is going on.
- It is also important for parents to manage their temptation to rush in and fix the issue. Solutions are important, as is space to feel listened to or understood.
- Frame any new boundaries around safety, rather than as a punishment or consequence. If there is a family decision to discontinue locked bedroom doors, for example, discuss with your child that although privacy is important, that this decision superceeds that value at the moment to ensure parents can step in if something dangerous is occurring. Emphasise that these actions are being taken to address the seriousness of the behaviour, and that the self harming indicates just how difficult it is to cope with distress right now.
- Talk with your child about what kinds of support they might need when thoughts of self-harmimg come up. Some young people want to be close with a safe person, whilst others want space and periodic check-ins. Some want active distraction from these thoughts, whilst others need calmness and re-centring.
Your child may not yet know exactly what they need in these moments, though they may have clearer ideas about what they don’t want. For example, if your child says “I don’t know, but it doesn’t help when you shout at me”, it may be worth asking if a calm discussion is more manageable.
- For young people who find it particularly difficult to tell someone when they are struggling, a traffic light system can be a helpful way to non-verbally signal how they are feeling. This could be made into a visible poster stuck on the outside of their door, or something communicated via text. As with any intervention, this requires some buy in from the young person and best suits those who are wanting help in difficult moments. Green – I’m feeling ok currently Amber – I’m starting to struggle Red – I need support
Chronic suicidality
Many young people experience on-going suicidal thoughts. Each person experiences these differently, and at varying levels of intensity. It is important to take all suicidal thoughts and gestures seriously. What we know is that for some young people, these thoughts can become more pressing and urgent, which raises the risk levels significantly. It is when these thoughts become more intense, or harder to ignore, that we might see a young person acting upon their suicidal thoughts.
For other young people, these suicidal thoughts can linger in the background without being frequently acted upon. Each of these scenarios requires a slightly different response.
As mentioned earlier in this post, any urgent and pressing risk will interfere with a therapy process. Life threatening suicidal behaviour or active suicidal threats requires an urgent response, meaning a call to 111 or local crisis team 09 846 8900 for real time support. A general thread of safety and stability must be in place for effective therapy to occur.
For a young person who is experiencing chronic suicidal thoughts, but is not intending or planning to act upon these, therapy may be a helpful intervention to assist in managing the impact of these thoughts. There are also important steps families can take to ensure risk is managed at home. Many of these strategies are listed above in more detail, though require some tailoring in specific response to manage suicide risk.
- Safeguarding the home continues to be an important first step for managing risk. If a young person experiences suicidal thoughts, the removal of any means for suicide may need to be more specific. Check out the CASA link above, with special attention towards locking away medications and home cleaning products as well as identifying ligature points
- Identify with your child when their suicidal thoughts are at their most intense. For some young people, evenings can be a time where these thoughts flare, meaning that adjustments to family routines may need to be made around this. This could mean that evening meals are reinstated, or there is an increased emphasis on spending evenings together, rather than retreating to separate spaces.
- Make a clear plan around supervision. Who will be supervising your child throughout the day, weekends, evenings. This will need to be a shared responsibility. It might be helpful to have a system of regularly checking in on your child.
- Inform your childs school about any potential risks. Suicide can be a difficult topic to talk about, and many young people experience intense shame about this. There can be a temptation to not tell people due to worries about how others will respond. That being said, risk increases when information is siloed. Sharing this responsibility also helps parents reduce risk of burnout.
This is not to say that your childs difficulties should be shared with everyone, but it will be important to identify safe people in your system who can assist in helping your child to feel protected.
- Support your child to keep their mind engaged and busy. Many young people experience worsening suicidality during the empty spaces in their lives where their minds have space to perseverate. It is optimal for your child to be engaged in distraction in relationship with someone they trust. This might mean going for regular walks or drives together, playing games or working on a craft together, re-engaging with sports or activities, talking about other aspects of life. Although distraction does not solve the issue, it does help in managing risk short term, strengthens healthy relationship connections and broadens the other aspects of life that your childs mind can connect with.
If your child is feeling low, depressed and amotivated, it may seem like they are resistant to engaging with anything. However, remaining isolated, sleeping often and shrinking the world down can intensify the inertia of low feelings.
- Employ TIPP skills together, to manage intense or overwhelming feelings and urges. More information here https://dialecticalbehaviortherapy.com/distress-tolerance/tipp/
- Don’t be afraid to step in and pull the parent card. Although adolescents in particular can be resistant to parents becoming more firm in their boundaries, there can also be a crucial sense of relief. Many young people link feelings of suicidality to feeling out of control, driven by overwhelming impulses, or helpless to enact change. As parents step in, they support their child by reinforcing the idea that there is a safe and containing structure around them, that there are thinking adults around them who know what to do, that there will be a way out of feeling this way which they do not have to find independently. This can be a complex balancing act- managing your adolescents growing wish for autonomy whilst also maintaining supportive “hands” around them. Conversely, if parents become more fearful and paralysed by their childs destructive behaviour, the opposite message can be reinforced; that the situation is indeed out of control and unmanageable.
- Be aware of critical and shaming responses. A suicidal young person may be acutely sensitive to perceived criticism and blame. Often, young people feel deeply at fault for the distress in the family. It may be useful for parents to seek their own therapy to ensure they have a safe and separate space to explore the many complex feelings that arise.
Disordered eating
Restricting food intake, exercising compulsively and controlling ones weight can be risky behaviours that lead into medical compromise and eating disorders. It is important to address unhelpful changes to eating patterns in the first instance, to avoid allowing a young person to spiral into further disordered eating.
The link between inadequate nutrition, mood regulation and anxiety is clear; an undernourished child is more likely to be irritable, have difficulty concentrating and may become exhausted or overwhelmed more easily. At the best of times, adolescents can eat in ways that may be considered unhealthy or unhelpful, such as skipping meals, choosing ‘junk’ foods more often or exploring diets and food trends which deviate from family norms.
It can be challenging to draw a clear line between unhelpful food habits and disordered eating. Certainly, if changes to your childs eating habits appear to be getting in the way of their ability to function at school, with friends, in sport or otherwise, it may indicate that your childs eating has become disordered.
- Take note of any significant weight changes. If your child appears to be losing weight, it may be important to take them to a GP for regular monitoring. Impacts of significant weight loss can be invisible and serious.
- Resume a closer eye around your childs food intake. Adolescents often have autonomy around what foods are taken to school, what snacks are selected at home, what is eaten for breakfast. Without oversight, these are areas which can swiftly fall off the radar, allowing opportunities for evasive meal skipping. If you have concerns about your childs relationship with food, start by taking note of what your child is eating throughout the day, and whether or not this is adequate for an active, growing young person. If it appears to have changed significantly, it may be time to enforce responsive boundaries about who is responsible for food at home.
- Be mindful of the way food and bodies are talked about at home. Children and adolescents are exposed to many, many conflicting messages about what constitutes ‘healthy’ eating, and what a ‘healthy’ body may look like. Young peoples’ bodies are in a natural state of change as they grow into adults. At times, your child may be bigger, smaller, taller, rounder, more or less fit. It can be unhelpful to foster an environment that is critical of these fluctuations, or to have other peoples bodies consistently approached with judgement. Avoid judgements about “good” and “bad” foods or bodies, instead reinforcing a general message that health and balance look different for everyone.
- Consider resuming routined family meals.
High levels of anxiety
Anxiety is a broad issue, experienced by each person in unique ways. Anxiety is an experience that is core to human experience, and cannot be eradicated in totality. Without any anxiety, one lacks the important signal which alerts us to risk or harm. However, for many, the anxiety system works in overdrive, signalling ‘danger’ even in safe situations. This might look like struggling to go to school, difficulties socialising, difficulties being away from home, difficulties toileting and other forms of avoidance. For some young people, heightened anxiety may present as panic or total shutdown. For others, they may lean towards compulsive, repetitive or ritualistic behaviours in an effort to cope with overwhelming anxiety. For others still, heightened anxiety may appear highly emotional, combative or oppositional. These fight, flight and freeze responses can be understood under the umbrella of anxiety. Much like disordered eating, problematic anxiety can pose risks to young people when the experience of anxiety is intruding upon their ability to engage fully in everyday areas of life; school, friendships, home life, activities.
- Identify any potential triggers which pose serious risk to the young person. A particularly risky behaviour can be young people who flee situations which provoke anxiety. This might include absconding from school, or leaving home to get out of a difficult interaction, or entering a state of panic in public. Utilise support people to manage the immediate risks associated with this behaviour. This will look different for each family, and will require a specific plan of what to do when the risk event occurs. For a young person who absconds from home, this might mean that there is a designated person who follows behind the young person at a safe distance, or a safe ‘escape’ place is identified that the young person can run to. There may be an agreement that the young person shares their location via their phone. There may be a time limit set on when family members come to retrieve the young person. Any steps that can be taken to reduce the level of panic and uncertainty, will be helpful in reducing the impact of risky behaviours. Managing risk such as this involves preparing an “emergency kit”, much like one would in preparation for a natural disaster- there is a hope that this kit is not required, though there is a readiness for if or when swift action is needed.
- Lean into predictability and routine. Overwhelming anxiety is a feeling of chaos, terror and uncertainty. Where possible, reducing environmental uncertainty can support young people experiencing anxiety. This might involve predictable home routines, predictable changes, predictable responses from others.
- Avoid avoidance. This point highlights a challenging balancing act which must be explored. As anxiety represents a fearful signal, families must offer reassurance without removing the perceived threat. Take, for example, a child who is intensely fearful of dogs. A full removal of dogs from the childs life may inadvertantly reinforce the idea that dogs are dangerous creatures which should be feared. At times, families say things such as “when the child is less anxious about dogs, then we will reintroduce dogs into her life”. However, in this instance there has been a removal of any practicing opportunities, strengthening the anxious grip that dogs may symbolise to the child. Conversely, forcing the child into a room full of dogs is likely to unhelpfully overwhelm and dysregulate the child.
The balancing act involves supporting the children to widen their window of tolerance gradually. This might mean slowly easing the child into experiences with dogs, reinforcing and reassuring that friendly dogs are in fact safe, and can be approached. It may mean the childs anxiety at first is spiked, however with repeated experiences such as this, the cognitive message can be strengthened; even when I feel anxiety feelings, I am safe. The example with dogs is perhaps a simplistic one. However, the message remains true; anxiety reduces through repeated experiences of feeling the anxiety and finding ways to persevere despite it.
- Management of parental anxiety. Parents who respond to their childs anxiety with their own anxiety, may inadvertantly heighten and strengthen the child’s fearfulness. Alternatively, parents who are able to remain calm and centered within themselves will be more effectively placed to help the child re-regulate.
- Identify any regulation skills that your child finds effective. Techniques such as manualised breathing, sensory modulation, meditation, mindfulness, journalling etc can be helpful in neutralising the intensity of anxiety in the moment. These skills can take time to identify, and time to practice.