different relationships , different situations / environments or even in the same relationship . Such as the bully previously being the Victim and then becoming the Persecutor : perhaps they were re-enacting trauma that happened to them . But it does not have to be this way . How do we break this cycle ?
We become more self-aware , recognize our own power , forgive ourselves for making mistakes , set boundaries , focus on what we can change and ask for help if needed . It is possible to switch roles to become more assertive , supportive and effective in our relationships .
PERSECUTOR
This subject is so vital because trauma leads to adverse childhood experiences ( ACEs ). The more ACEs an individual has prior to the age of 18 , the more likely they are to have physical and mental health issues later in life , in addition to high-risk behaviors and suicide . Having 4 + ACEs causes a 4-to-12-fold increase in alcoholism , drug abuse , depression and suicide attempt . The original ACEs study was done in 1998 . Although it did not include bullying and had limitations related to demographics ( mostly white , highly educated , over 50 years old ), there have been multiple other studies since then that support and expand the ideas of the original study . I believe the more we as health care providers are aware of trauma and how it can affect the body , brain and behavior , the better we can be at preventing disease , high-risk behaviors and suicide .
As with bullying , suicide affects all ages and all parts of society . The national suicide rate has been increasing according to the Centers for Disease Control and Prevention data . The rate has increased 33 % between 1999-2019 . It is the second leading cause of death for people ages 10-34 , the fourth leading cause for people ages 34-54 , and the fifth leading cause among people ages 45-54 . However , the CDC reports that some groups ( particularly minority groups , including LGBTQ +) have remarkably higher suicide rates than others . This makes sense because these groups are often marginalized and experience more trauma , as minorities . More trauma leads to more ACEs , which lead to a higher risk of suicide .
I believe the data . And I suspect the rates of suicide , suicide attempts and suicidal ideation have been even higher since the COVID-19 pandemic began in March 2020 . In practice , I ’ m seeing more teens and children ( yes , children ) presenting with suicidal ideation . Some even have a history of suicide attempt ( s ). Often , these symptoms occur along with depression , and that is what I end up treating . Suicidal thoughts are a common symptom of depression . However , they can occur in other diagnoses and circumstances as well . They are not exclusive to depression . I try to ask
VICTIM
TAKING A STAND AGAINST BULLYING
RESCUER
Karpman , S . ( 2014 ). A Game Free Life . USA : Drama Triangle Publications
all patients about suicidal thoughts regardless of age or symptoms / diagnosis . It ’ s easy to think , “ They ’ re only 8 , how could they even know what that is ?” or “ They just have ADHD , why would they have suicidal thoughts ?” These assumptions are simply not true .
I typically see patients in the context of a crisis or aftercare from a psychiatric hospitalization , so it is possible I am seeing a skewed population . But what if I ’ m not ? The CDC numbers make me think I might not be . I usually ask patients about suicidal thoughts in my routine " safety questions " at the evaluation appointment and then at follow-up appointments . If they ( or the parent / guardian ) react like “ Why would you ask me that ?!” then I respond that I ask everyone about it and that I try not to assume anything .
But I won ’ t know unless I ask . They are important questions . These questions bring to mind another important topic : believing the patient when they tell you something . I ’ ve encountered many situations where providers , parents and / or families do not believe the patient . This is even more crucial when a patient discloses suicidal thoughts or a history of trauma . I ’ ve had some parents who say they don ’ t believe their kid was truly suicidal and was just trying to get attention . This can be invalidating and unhelpful . I must err on the side of believing the patient - especially female ones who may face even more barriers than male ones - that can be therapeutic because I am validating their experience . This can be true for suicidal thoughts , trauma and bullying . More notably , this creates a relationship based on safety and trust . Being validating and focusing on safety can help people to heal from trauma and is one way to provide trauma-informed care .
People often get hurt in relationships , but they also can heal in relationships . We can use our doctor-patient relationship to heal , whether it be physical or emotional pain . We should examine interactions we have with patients , families and communities to see
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