The period of adolescence is marked by increased risk of various mental disorders, including anxiety disorders and depression, contributing to increased suicide risk. Reference Boden, Fergusson and John Horwood1 Suicide is a leading cause of death for young people worldwide. 2 Beyond the tragic loss of life, many young people experience suicidal thoughts and the associated psychological distress. In 2019, a nationwide report of secondary-school students in the USA revealed that 18.8% of adolescents had considered suicide, 15.7% had made plans and 8.9% actively attempted suicide at least once during a 12-month period. Reference Ivey-Stephenson, Demissie, Crosby, Stone, Gaylor and Wilkins3 Suicide prevention has been deemed a global health imperative, 2 and timely intervention is pivotal to alleviate the psychological distress of these young people and to prevent their premature deaths.
The protective role of parents (i.e. primary caregivers) against youth suicide is well-recognised, Reference Czyz, Horwitz, Yeguez, Ewell Foster and King4,Reference Sahle, Reavley, Li, Morgan, Yap and Reupert5 and a family-focused response is considered critical for efficacious adolescent interventions. Reference Brent, McMakin, Kennard, Goldstein, Mayes and Douaihy6,Reference Glenn, Franklin and Nock7 Unlike many risk factors for adolescent suicide (e.g. past history of trauma, temperament, biological sex Reference Goldney, Wilson, Grande, Fisher and McFarlane8,Reference Moller, Davey, Badcock, Wrobel, Cao and Murrihy9 ), which are difficult or impossible to modify, parenting behaviours are amenable to change. Robust evidence has found that parenting factors such as parental warmth, parent–adolescent cohesion, communication and connectedness are protective against adolescent suicide. Reference Sahle, Reavley, Li, Morgan, Yap and Reupert5,Reference Perquier, Hetrick, Rodak, Jing, Wang and Cost10,Reference Whitlock, Wyman and Moore11 Further, parents have a pivotal role in monitoring their adolescent’s risk, encouraging adaptive coping strategies, providing emotional support and limiting access to lethal means. Reference King, Foster and Rogalski12 Although adolescents experiencing suicidality have low rates of help-seeking, Reference Michelmore and Hindley13 parents are intrinsically motivated to support their children’s well-being. Reference Yap, Fowler, Reavley and Jorm14 As such, parents are a key partner in adolescent suicide prevention efforts.
Yet, despite their importance, parents of adolescents experiencing suicidal crises report feeling ill-equipped to emotionally support their adolescent and safeguard their well-being. Reference Czyz, Horwitz, Yeguez, Ewell Foster and King4 Parents describe their adolescent’s suicidal crises as a traumatic experience, and report feelings of helplessness, guilt, fear and loneliness. Reference Hickey, Rossetti, Strom and Bryant15–Reference Weissinger, Catherine, Winston-Lindeboom, Ruan-Iu and Rivers17 Consistently, research has highlighted parents’ unmet needs and desire for greater parenting support when adolescents experience suicidal crises, Reference Miettinen, Kaunonen, Kylmä, Rissanen and Aho16–Reference Rheinberger, Shand, Mcgillivray, Mccallum and Boydell19 as well as their disappointment with the lack of parenting support from healthcare systems and professionals following these suicidal crises. Reference Weissinger, Catherine, Winston-Lindeboom, Ruan-Iu and Rivers17,Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20 As such, these studies underscore parents’ desires for greater support, including that from trained mental health professionals.
Although it is clear that parents require greater support in managing their adolescents’ suicidal crises, particularly from professionals, little is known about the specific types of support parents desire and how such support can be optimally delivered. Developing a deeper understanding of parents’ support needs is necessary to better support parents and develop interventions. Research has highlighted parents’ preference for general parenting information to be presented online over traditional face-to-face approaches. Reference Baker, Sanders and Morawska21,Reference Metzler, Sanders, Rusby and Crowley22 Online interventions hold promise, as they can overcome logistical barriers commonly faced by parents (e.g. scheduling conflicts, childcare arrangements, transportation time, work commitments and associated financial costs Reference Finan, Swierzbiolek, Priest, Warren and Yap23 ). As parents of adolescents experiencing suicidal crises desire greater support from professionals, Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20 a therapist-assisted online parenting programme can address the current resource gap. However, there is a lack of digital interventions to meet the needs of parents in this context. Reference Torok, Calear, Smart, Nicolopoulos and Wong24 Hence, a deeper understanding is needed of whether an online parenting programme with therapist involvement can address these parents’ needs, and how.
Understanding the challenges of parenting an adolescent experiencing suicidality, along with the associated support needs, necessitates recognising the broader context in which these experiences unfold. The social–ecological model has been used as a framework for suicide prevention, Reference Cramer and Kapusta25 and it has been argued that suicide prevention interventions should consider the interplay between the individual, their interpersonal relationships and the wider community/societal system. Reference Cramer and Kapusta25 Therefore, the support needs of parents exist within a system including the adolescent and healthcare systems involved in the adolescent’s care. Although parents are pivotal in providing an understanding of their lived experience of parenting an adolescent at risk of suicide, they can only offer their subjective viewpoints. Reference Weissinger, Catherine, Winston-Lindeboom, Ruan-Iu and Rivers17 Therefore, it would be helpful to consider the lived experience and support needs of these parents through a multifaceted lens, encompassing the viewpoints of the parent, adolescent and healthcare systems supporting the adolescent’s mental health.
Aims
This study has two aims: (a) to explore the lived experience of parenting an adolescent during suicidal crises, from the viewpoints of parents, young people and experts; and (b) related to this lived experience, to understand how a therapist-assisted online parenting programme can meet parents’ support needs.
Method
Research design
We adopted a phenomenological approach to explore the subjective experiences of parenting a suicidal adolescent and, in relation to this lived experience, identify what kind of supports a therapist-assisted online parenting programme should provide. Three groups of participants were interviewed to reflect the social–ecological lens, i.e. parents, young people and experts in youth mental health/suicide prevention. These groups were chosen as they were considered the key stakeholders in parent–adolescent relationships and the adolescent’s recovery. We used Braun and Clarke’s Reference Braun and Clarke26 inductive approach to interpret the data within a critical–realist framework, where both semantic and latent meanings were identified and data interpretation focused on the lived experience of participants.
Ethical approval
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving human patients were approved by Monash University Human Research Ethics Committee (approval number #28055). For young people under 18 years of age, both the parent and young person were asked to review the explanatory statement written for the young person. If both agreed to participate, the parent was required to provide informed consent. Verbal assent obtained from the young person was required before beginning the interview. Thus, before participation, written informed consent was obtained for all participants.
Recruitment and participants
We recruited participants through sharing flyers with professional networks, online community noticeboards and social media sites. Parents and their adolescents who participated in a previous clinical trial of an online, therapist-supported parenting intervention for parents of adolescents with depression and/or anxiety disorders (Australian New Zealand Clinical Trials Registry identifier ACTRN12615000247572) and provided consent to be contacted in future were also invited. Reference Khor, Fulgoni, Lewis, Melvin, Jorm and Lawrence27
All participants needed to live in Australia, speak English, have stable internet access and were reimbursed AUD$40 per hour for their time. Parent participants had lived experience of parenting an adolescent (aged 12–18 years) who experienced depression and suicidal thoughts or behaviours. Young people (aged 15–25 years) were eligible if they had lived experience of depression and suicidal thoughts or behaviours when they were adolescents (aged 12–18 years). Although young people under 18 years of age were eligible to participate, no such participants expressed interest, and therefore, parental consent was not sought. Finally, experts were eligible if they had over 3 years of experience working in the field of youth mental health and suicide prevention (henceforth referred to as experts). Table 1 shows the demographic characteristics of the participants.
Demographics of stakeholder groups
a Clinical backgrounds included psychologist, social worker and psychotherapist. One participant was both a parent of a suicidal adolescent and a clinical expert, and was counted in both sample groups as they provided their perspectives from both roles and provided clarification if required. The participant is uniquely identified as ‘expert parent’ in contributing data.
Data collection
The research team developed semi-structured interview guides, specific for each participant group, which broadly focused on understanding the lived experiences of parenting an adolescent experiencing a suicidal crisis, and how parenting challenges were overcome. Further, interview questions explored how a therapist-assisted online parenting programme could support parents’ needs. For context, all participants were provided a description of the prior clinical trial and a brief description of the existing online parenting intervention evaluated therein. Reference Khor, Fulgoni, Lewis, Melvin, Jorm and Lawrence27 Elements of the intervention were described (e.g. intervention content, modes of delivery and therapist involvement), and participants were asked if and how the existing programme could be adapted to be more suitable for parents caring for a suicidal adolescent.
Interviews were conducted online by A.C. (a provisional psychologist and doctoral student in clinical psychology), using Zoom, version 5.7 for Mac iOS (Zoom Communications, San Jose, California, USA; see https://www.zoom.com), with audio and video recording. A.C. was not a researcher on the prior clinical trial. Interviews lasted 60–90 mins each, and were conducted from July to August 2021. Participants were encouraged to talk freely about their experiences and parents’ support needs, with prompts provided to encourage elaboration as needed (e.g. ‘Can you tell me more?’). Because of the sensitive nature of the interview, parents and young people were called by A.C. within 24 h after their interview, to assess whether any distress occurred and to provide crisis supports as required.
Data analysis
All interviews were initially transcribed by a trusted third party, Artificial Intelligence software, Descript version 7.0.4 for Mac (Descript, San Francisco, California, USA; see https://www.descript.com/). Interviews were then manually corrected for accurate verbatim transcription by A.C. or a trained research assistant. Reflexive thematic analysis was conducted by A.C., adhering to the six phases outlined by Braun and Clarke. Reference Braun and Clarke26 A.C. undertook complete coding of transcripts, using Microsoft Word comments and a thematic analysis coding management macro (Open Science Framework; see https://doi.org/10.17605/OSF.IO/ZA7B6), converting Microsoft Word comments to a Microsoft Excel spreadsheet (Microsoft Office, version 16.89.1 for Mac iOS). Candidate themes were developed by A.C. by triangulating insights across stakeholder groups. The research team contributed to the review and refinement of the candidate themes. Candidate themes were then recursively developed and discussed with the research team until the themes were conceptualised and defined.
Results
Lived experience of parenting a suicidal adolescent
Three themes, each with three subthemes, were developed to reflect the experience of parenting a suicidal adolescent: (a) traumatising emotional experience, (b) uncertainty and (c) parent empowerment. Figure 1 presents a visual representation of the themes, subthemes and their interrelationships. Further, Table 2 presents indicative verbatim quotes to illustrate each theme and subtheme.
Thematic map of the lived experience of parenting a suicidal adolescent.
Themes, subthemes and illustrative quotes of the lived experience of parenting a suicidal adolescent
Traumatising emotional experience
Parents described the impact of parenting a suicidal adolescent as taking a profound emotional toll. Although parents did not explicitly call the experience traumatising, many cried as they recounted learning that their adolescent was suicidal and found it challenging to put the emotional impact into words. Parents described the shock of the experience and how learning that their adolescent was suicidal changed their normal day-to-day life. It upended the assumption that their child was safe, and made them question their identity as a parent. Further, parents described traumatic symptoms, including intense and prolonged distress, difficulty sleeping and hypervigilance. As such, this experience was latently conceptualised as a traumatising emotional experience. Similarly, experts described the profound impact that parenting a suicidal adolescent had on a parent’s sense of identity. When young people recounted their parent’s reactions to their suicidality, they focused less on their parent’s experiences and more on their own needs. However, they identified more externalised expressions of their parent’s traumatising emotional experience, including anger and fear. Comparatively, only subthemes of anguish, guilt and loneliness were expressed in interviews by parents and experts, as these were likely more internalised emotional experiences.
Anguish
Upon learning of their adolescent’s suicidality, parents described the emotional experience as one of unbearable pain and hurt. Some expressed this experience as leaving their internal world broken. Similarly, experts described the anguish parents experience and how such anguish could impact the overall experiences of their parenting to date.
Guilt
Parents felt guilty that they were unable to prevent their adolescent’s suicidal thoughts or behaviours. Further, they expressed guilt believing that their own parenting drove their adolescent to suicidality. Similarly, experts described how parents’ sense of guilt can lead to doubt in their own parenting abilities.
Loneliness
Many parents expressed feelings of loneliness upon discovering their adolescent’s suicidality, particularly immediately following a suicide attempt. Parents described a perceived lack of support from mental health professionals, leading to further feelings of isolation. Moreover, as adolescent suicidality was not a topic openly spoken about among family and friends, parents found it challenging to seek solidarity from informal supports because of fears of being judged for their parenting and not being understood by others. Further, experts elaborated upon this notion, expressing that parent’s loneliness and lack of initial support can lead to cynicism toward seeking both formal and informal supports in the future.
Uncertainty
Parents described a pervasive sense of uncertainty following their adolescent’s suicidal behaviour. They expressed self-doubt in their own parenting ability, not knowing how to emotionally support their adolescent, and if they could prevent future adolescent suicide attempts. Experts empathised, describing that such a task was challenging even for a trained professional. Again, young people were less able to identify with the uncertainty that their parents experienced. However, some young people reflected upon what appeared to be externalised expressions of their parents’ uncertainty. The young people acknowledged that their parents lacked an understanding of how to respond to their emotional distress, leading the young people to feel frustrated and rejected.
Helplessness and powerlessness
The sense of helplessness and powerlessness parents felt in relation to their adolescent’s suicidality perpetuated their feelings of uncertainty. Such helplessness and powerlessness manifested from parents’ acknowledgement of their adolescent’s increasing autonomy and their inability to exert control. Parents described wanting their adolescent to engage in professional support and the desire to continuously monitor them for signs of suicidality, but acknowledged that adolescents can be unreceptive to either. Moreover, parents described feeling powerless to prevent their adolescent’s suicide, acknowledging that their adolescent’s behaviours are not fully within their control. Experts expressed similar sentiments and described how the pervasive lack of parental professional support and resources following an adolescent’s suicidal crisis can further exacerbate parents’ feelings of helplessness and powerlessness. Again, young people did not explicitly acknowledge their parents’ sense of helplessness and powerlessness, yet reflected that their parents’ efforts to support them could be met with resistance. Despite parents trying their best to support the adolescent, the outcome ultimately depended on whether they were receptive to their parents’ help. As such, when adolescents resisted these efforts, parents were left feeling powerless and helpless to influence the situation.
Anxiety and fear of future suicide attempts
Parents described a large contributing factor to their uncertainty was the worry that their adolescent may have future suicide attempts. Parents expressed worries that if they do the ‘wrong thing’ this may lead their adolescent to suicide. Experts reflected upon how parents’ fears were understandable, given the high stakes life or death situation if there was a suicide attempt. Young people were less able to directly articulate their parents’ fear, but were able to acknowledge it when it was explicitly mentioned by their parent or instead identified that they had contributed to their parents’ stress.
Strained parent–adolescent communication and trust
Notably, all stakeholders commented on the breakdown of parent–adolescent communication and trust when an adolescent experiences a suicidal crisis, particularly after a suicide attempt. Parents describe finding it difficult to speak to their adolescent about their suicidal thoughts and behaviours, and even when they do, adolescents are often unwilling to engage. As such, this strained communication leads to a sense of mistrust, where parents do not believe or trust that their adolescent will not engage in suicidal behaviours. This strained communication and mistrust further perpetuates parents’ uncertainty about how they can emotionally support their adolescent and prevent their suicide if the adolescent is withholding information about their mental state or is unable to express how they are feeling. On the other hand, young people described not trusting their parents to respond in ways that would be emotionally supportive or helpful, hence finding it challenging to engage in a conversation about suicide with their parents. Experts similarly observed the breakdown in the parent–adolescent communication and trust.
Parent empowerment
Overall, parent empowerment was considered a major influence on parents’ ability to recover from the traumatising emotional experience and help tolerate the inherent uncertainties of parenting a suicidal adolescent. Parent empowerment was conceptualised as the belief that they have a valuable role in preventing their adolescent’s suicide, and undertaking the behaviours to do so. Subthemes of parent empowerment included persistence and hope, proactivity and parent–adolescent connection.
Persistence and hope
All stakeholder groups described the importance and inherent challenge of parental persistence in emotionally supporting their adolescent when they are suicidal, and continuing to hold hope that their adolescent’s recovery is eventually possible. Nevertheless, participants indicated how pivotal such persistence and hope are in supporting adolescents’ recovery, and helping parents to remain resilient despite setbacks.
Proactivity
Parents and experts described parents’ proactivity (i.e. ability to continue to monitor and stay alert to potential signs of suicide) as important to being empowered within their parental role. Parents’ ability to maintain attentiveness and responsiveness would support early intervention and therefore mitigate the complexity of the situation. Further, it would foster parents’ self-efficacy that they can meaningfully support their adolescent when they are suicidal. Interestingly, young people’s perspectives highlighted an important tension in this subtheme. Specifically, some young people described their parents’ proactivity as invasive, controlling and affecting their sense of autonomy and boundaries. Young people described their parents’ frequent monitoring as overwhelming, and their parents’ insistence on them engaging in professional support as frustrating.
Parent–adolescent connection
All stakeholder groups agreed that parent–adolescent connection supports parent empowerment. When parents feel a sense of closeness to their adolescents, it supports parents’ recovery from the traumatising emotional experience and their ability to tolerate uncertainty. Parents described how increased closeness with their adolescent led to noticeable changes in their adolescent’s well-being and improved communication. Similarly, young people and experts agreed that an important aspect of caring for a suicidal adolescent is being able to be there for the adolescent as opposed to being preoccupied with ‘getting it right’ or ‘fixing’ the adolescent.
How a therapist-assisted online parenting programme could meet parents’ support needs
In the context of a therapist-assisted online parenting programme, parents described six aspects as critical in addressing parents’ needs when their adolescent is experiencing suicidal crises. These six aspects are described as the following themes: (a) validation and support, (b) practical and tailored suicide prevention strategies, (c) support to rebuild the parent–adolescent relationship, (d) parental self-care, (e) flexible and accessible modes of delivery and (f) understanding non-suicidal self-injury in the context of suicide prevention. Figure 2 presents a map of these themes and subthemes, and Table 3 provides indicative verbatim quotes.
Thematic map illustrating themes and subthemes of how a therapist-assisted online parenting programme can meet parents’ support needs.
Themes, subthemes and illustrative quotes about meeting parents’ needs through a therapist-assisted online parenting programme
Validation and support
To meet parents’ needs through an online parenting programme, parents and experts described the importance of being compassionate to the parent’s individual experiences and to provide validation of their efforts. Such empathy and recognition of the unique parenting experience was deemed necessary by parents following their traumatising emotional experiences. Further, encouragement from an understanding individual can support a parent’s sense of persistence and hope especially if they feel helpless. Three further subthemes were developed to encapsulate the kind of validation and support parents may benefit from.
Trained professional parenting support
Parents described the value of a trained professional supporting them with parenting skills specific to suicide prevention and providing them with validation. Further, support from reputable professionals was emphasised given the clinical acuity of their adolescents. Similarly, experts described that a trained professional with qualifications would be ideal to deliver this support, yet acknowledged the limitations in the availability of such a workforce. In line with parents and experts, young people also saw the value of parents receiving trained professional parenting support, expressing that this could alleviate tensions of having the same therapist work with both the adolescent and parent. Further, such support could offer an opportunity for parents to learn specific parenting content.
Lived experience peer support
All stakeholder groups believed parents would benefit from the support of parents with lived experiences of parenting a suicidal adolescent. It was described that other parents with lived experience would inherently understand the experiences of parenting a suicidal adolescent and could offer strategies that had helped their adolescent. Further, such peer support from those who have overcome these challenges could offer parents hope that adolescent suicidality can eventually be overcome.
Understanding the parent’s unique experience
Although parents and experts expressed the need for understanding and support, the caveat was that such support, whether it be through formal or informal support systems, needed to be framed within the experiences of each individual. As such, validation and support must first be founded on the deep understanding of the parent’s unique circumstances.
Practical and tailored strategies for adolescent suicide prevention
Practical and tailored strategies for adolescent suicide prevention was described by stakeholders as important for parents caring for a suicidal adolescent. Such strategies could help parents better tolerate the uncertainty, by feeling more equipped with specific suicide prevention skills they could draw upon.
Practical suicide prevention strategies
When parents were asked how a therapist-assisted online parenting programme could meet their needs, most responded with ‘how to’ requests, including how to speak about suicide, recognise signs and link their adolescent to professional supports. Although parents did not explicitly ask for practical strategies for adolescent suicide prevention, their request for support in ‘how to’ was conceptualised as the latent construct of practical strategies for adolescent suicide prevention. Similarly, experts described the benefit of providing parents with practical strategies, particularly for challenging situations such as starting a conversation about suicide. Further, some young people recounted that their parents latched onto practical strategies as a means to contributing meaningfully to their care.
Tailored suicide prevention strategies
However, all stakeholder groups expressed that practical strategies would only be efficacious if they were tailored to the unique parent and adolescent. Parents described a sense of frustration when practical strategies were not grounded in their own experiences. Similarly, experts described that suicide prevention strategies needed to be provided in the specific context of the parent and adolescent. Finally, some young people described that generic practical strategies that did not resonate with their experiences were perceived as unacceptable.
Support to rebuild the parent–adolescent relationship
All stakeholders emphasised the need for the programme to facilitate the rebuilding of the parent–adolescent relationship. This need was described as critical if there is strained communication and trust following the adolescent’s suicidal crisis. Therefore, stakeholders emphasised that the parenting programme should not only focus on suicide prevention skills, but strategies that could facilitate greater parent-adolescent connection. Young people described that this would, in turn, allow adolescents to feel more comfortable to disclose their suicidal thoughts.
Parental self-care
All stakeholders described the emotional toll that caring for a suicidal adolescent can have, particularly as the role of a carer is long term. As such, they emphasised the importance of incorporating strategies to facilitate parents’ self-care. In particular, experts expressed that self-care content needed to be emphasised, as parents may feel a sense of guilt in prioritising their needs over their adolescents’.
Flexible and accessible modes of delivery
All stakeholders agreed that the efficacy of an online parenting programme was contingent on the programme being feasible and accessible to the parents. In particular, parents and experts reflected upon the logistical difficulties of completing a programme when parents are typically busy with many commitments. All stakeholders described the importance of being able to deliver information in ways that would cater toward the diverse learning preferences of parents (e.g. videos, text, audio and role-plays). Additionally, stakeholders discussed that any digital platform needed to be simple to use – accounting for parents’ differing levels of comfort with technology.
Understanding non-suicidal self-injury in the context of suicide prevention
Parents described that the programme should provide information on understanding non-suicidal self-injury in the context of suicide prevention. Many parents described their uncertainty and fears of future suicide attempts being linked to their adolescents’ non-suicidal self-injury. Parents discussed being worried about the co-occurrence of non-suicidal self-injury and suicidal behaviours, and were unsure about how they differ and how to support their adolescent accordingly. Young people agreed that they would find it beneficial for their parent to understand non-suicidal self-injury, given its co-occurrence with suicide and that non-suicidal self-injury is on the spectrum of self-harm. However, there was a split in expert opinion. Some experts agreed with parents and young people, whereas others were concerned that such content may be too confusing and detract parents’ focus from suicide prevention.
Discussion
This study illustrated the lived experience of parents supporting their adolescent during suicidal crises by triangulating the perspectives of parents, young people and experts in youth mental health and suicide prevention. Further, it highlighted the support needs of parents in the context of a therapist-assisted online parenting programme. The experience of parenting a suicidal adolescent was considered to have a traumatising emotional impact. Moreover, parents experienced a sense of uncertainty, including feelings of helplessness about how to best support their adolescent and fears of a future suicide attempt. To overcome such challenges, stakeholders described the importance of parent empowerment. Related to these experiences, six key support needs for a therapist-assisted online parenting programme were identified.
In line with prior literature, the emotional impact of being a parent to a suicidal adolescent was profound, leaving parents’ internal world feeling shattered; Reference Weissinger, Catherine, Winston-Lindeboom, Ruan-Iu and Rivers17,Reference Rheinberger, Shand, Mcgillivray, Mccallum and Boydell19,Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20 consequently, parents’ support needs included validation and support of their experiences. Parents described the importance of empathy and compassion from both formal and informal supports, and how such support must be founded on a deep understanding of the parents’ current experiences. Further, parent empowerment was considered critical to helping parents overcome the traumatising emotional experience and the uncertainty inherent in adolescent suicidal crises. The theme was conveyed as a pivotal agent of change, enabling parents to shift from uncertainty to a state of agency. Yet, as conveyed by stakeholders, persistently maintaining hope in their adolescent’s recovery and being consistently proactive with signs of suicidal crises is much more challenging to achieve in practice. Thus, to address these challenges parents expressed a need for encouragement and validation from both formal and informal supports, to provide guidance, explore parenting strategies and act as a source of encouragement.
Consequently, a therapist-assisted online parenting programme may meet this need as a therapist would be well-placed to explore the unique circumstances of the parent, and provide validation and support for the parent’s experiences. Indeed, there may also be an opportunity to consider how lived experience peer support could be embedded into a parenting programme for adolescent suicide prevention. Such findings are consistent with other studies describing parents’ desire for lived experience peer support when their child is experiencing mental health challenges. Reference Smout, Melvin, Jorm and Yap28–Reference Wong and Shorey30 However, pragmatic considerations must be taken into account in providing such a service and the risks involved, especially given the clinical acuity of adolescent suicidality. To ensure such support is delivered effectively and safely for both the peer worker and parent, thorough training and supervision would be needed. Although family peer workers offer powerful opportunities for connection and support to parents, parents may seek clinical expertise about how to navigate adolescent suicidality, which peer workers may not be formally trained to provide. Therefore, efforts to co-design services with parents, peer workers and clinicians are needed to address the demand for delivering lived experience support.
Additionally, self-care emerged as a support need, given the traumatising and distressing emotional experience of learning about their adolescent’s suicidality and being confronted with their potential death. Such findings point toward the importance of interventions for parents with suicidal adolescents incorporating psychoeducation about self-care. However, experts described that parents may have challenges with engaging in self-care, deprioritising their own self-care to support the well-being of their adolescent. As such, this may warrant therapists exploring cognitive barriers to parental self-care and how such barriers can be overcome.
The uncertainty that parents experienced when caring for a suicidal adolescent aligns with prior research describing how parents often feel helpless and overwhelmed in their newfound role of caring for a suicidal adolescent. Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20,Reference Boulter and Rickwood31,Reference Logan and King32 Hence, parents desired practical and actionable suicide prevention strategies that would better equip them should a future suicidal crisis occur. Examples of practical and actionable suicide prevention strategies include information about how to have a conversation about suicide, signs of adolescent suicide risk increasing, and equipping parents with information about how and when to access emergency services. Yet notably, practical strategies must be personalised to the parent, which requires an element of understanding the unique parent–adolescent relationship. Thus, if a therapist-assisted online parenting programme were to be developed, the therapist must first allow time to understand the dynamics of the parent and adolescent before the provision of practical strategies. Further, although practical strategies including how to have a conversation about suicide with an adolescent could be delivered online, such content would require a therapist to support parents to tailor it to their own circumstances. Otherwise, generic practical strategies are less likely to be helpful, and may be deemed unacceptable by the parent and adolescent.
Another area which perpetuated parents’ uncertainty was their difficulty with understanding non-suicidal self-injury in the context of suicide prevention. Consequently, parenting interventions for adolescent suicide prevention should also consider providing psychoeducation about non-suicidal self-injury to help alleviate some of this uncertainty. Yet, some experts considered information on non-suicidal self-injury may detract focus from suicide prevention or lead parents to greater confusion and overwhelm. Thus, the introduction of non-suicidal self-injury psychoeducation would need to be carefully considered to prioritise clarity and maintain focus on suicide prevention. For a digital intervention, this may involve developing clearly distinguished modules around suicide prevention and non-suicidal self-injury. Further, therapists should consider discussing non-suicidal self-injury with parents, and its relevance to their adolescent’s situation. Such support could help parents understand their adolescent’s non-suicidal self-injury in the context of suicidal behaviours, and how parents’ approach to seeking support for their adolescent may vary accordingly.
Given the strained communication and trust between the parent and adolescent, rebuilding the parent–adolescent relationship was identified as a key support need. Such findings echo prior literature in highlighting the strain an adolescent’s suicidal crisis can have on family communication and the parent–child relationship. Reference Rheinberger, Shand, Mcgillivray, Mccallum and Boydell19,Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20,Reference Byrne, Morgan, Fitzpatrick, Boylan, Crowley and Gahan33 Thus, such findings necessitate the importance of incorporating general strategies for parents to connect with their adolescent (e.g. ways to communicate and express parental warmth). Yet, our findings reveal the tensions that may occur as parents attempt to rebuild this bond with their adolescent. Although increased parental monitoring of their adolescent’s risk is seen as a key element to parent empowerment, it can also lead adolescents to feel frustrated by what they perceive as intrusiveness and a lack of trust. Again, such nuances suggest the need for therapist support where parenting strategies must be tailored to the unique circumstances of the parent–adolescent relationship. Nonetheless, rebuilding the parent–adolescent relationship, including trust and communication, may support adolescents to better tolerate increased parental monitoring.
Finally, a parenting programme must be flexible and accessible to parents caring for a suicidal adolescent. Consistent with prior research, parents described having very little parental support and resources when caring for a suicidal adolescent. Reference Weissinger, Catherine, Winston-Lindeboom, Ruan-Iu and Rivers17,Reference Lachal, Orri, Sibeoni, Moro and Revah-Levy20 As such, any parenting intervention should be easily accessible and minimise barriers to registration and use. This is of particular importance to this subset of parents, as limited accessibility may reinforce feelings of helplessness and powerlessness. Additionally, interventions should consider the logistical demands of parents’ daily lives. Consequently, digital interventions appear ideal in providing this flexibility, where parents can access evidence-based information at their own convenience (e.g. if interrupted, they can save their progress and resume the programme). A digital programme that could be used flexibly and allow parents to engage at their convenience would likely overcome some logistical barriers. However, such flexibility may be more challenging to accommodate for therapists, given therapists’ need to manage competing work demands and other clients. Yet, where possible, if therapists could accommodate parents’ need for flexibility, this could provide substantial benefits (e.g. offering shorter session times or telehealth options).
In sum, our findings highlight the merit of developing a therapist-assisted online parenting programme to support the needs of parents caring for a suicidal adolescent. Such a programme could offer parents many advantages such as flexibility, accessibility and evidence-based guidance, alongside providing understanding and validation of parents’ unique experiences and tailoring of the strategies. Currently, interventions for adolescent suicide prevention largely focus on providing adolescent-focused interventions when they are suicidal, leaving parents without tailored and practical support. Reference Bailey, Robinson and Witt34 Yet, there are no systems that meet these support needs. Our study provides a preliminary step in identifying how a therapist-assisted digital parenting programme could better support these parents’ needs, and in turn, empower parents to believe that they can indeed help their adolescent.
Limitations
The current study’s findings should be considered within the context of certain limitations. First, the primary objective was to capture the breadth of perspectives when parents are caring for a suicidal adolescent, and therefore, we interviewed multiple stakeholder groups. A compromise had to be made in terms of the small sample sizes within each stakeholder group. Thus, our findings may not be generalisable to the experiences and perspectives of all parents, young people and experts. Second, the parent sample consisted of mostly mothers (89%); therefore, our results may not reflect the lived experiences and support needs of fathers. Future research should aim to include a larger and more diverse sample to capture broader perspectives. Third, no parent–adolescent pairs were interviewed. Including such pairs may have offered a fuller understanding of the suicidal crisis on the family, support requirements and potential differences in perspective between parents and adolescents. Finally, the self-selecting nature of the participants may introduce a bias, as those who chose to participate might be more proactive or motivated to seek support, which may not represent the experiences of all parents of suicidal adolescents.
In conclusion, our study describes the lived experience of parents when their adolescents experience suicidal crises. Our study highlights parents’ support needs and, consequently, proposes essential elements for a therapist-assisted online parenting programme that is responsive to the multifaceted needs of parents. These findings provide insights into how a therapist-assisted online parenting programme can support both the well-being of parents and the recovery of their adolescents.
Data availability
A summary of the data that support the findings of this study are available on request from the corresponding author, M.B.H.Y. The data are not publicly available owing to their containing information that could compromise the privacy of research participants.
Acknowledgements
We are grateful to the participants in this study and thank them for sharing their expertise and perspectives.
Author contributions
All authors made substantial contributions to the conception or design of the work (G.A.M., M.B.H.Y., A.F.J., L.W., M.C.C.-B., C.A.S. and P.O.), or to the acquisition (A.C.), analysis or interpretation of data (A.C., L.W., M.B.H.Y., G.A.M., M.C.C.-B. and C.A.S.). A.C. drafted the manuscript, and all authors reviewed and approved the final version to be published. A.C. has full access to all the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors share responsibility for the final version of the work submitted and published.
Funding
We gratefully acknowledge that this research was funded by Suicide Prevention Australia Limited for a Suicide Prevention Australia Innovation Grant, which was awarded to M.B.H.Y., G.A.M. and A.F.J. A.C. is supported by the Australian Government Research Training Program Scholarship for their candidature in the Doctor of Philosophy (Clinical Psychology) at Monash University. The contents of the published material are the responsibility of the relevant authors and have not been approved or endorsed by Suicide Prevention Australia.
Declaration of interest
None.
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