How Do You Actually Help a Suicidal Teen?

The Therapy Issue

It's a dark time for therapists treating adolescents in despair. But some things do work.

Credit...Illustration by Sophi Miyoko Gullbrants

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By Maggie Jones

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Early one morning last year, Dr. Daniel Bender, a psychiatrist at a child-and-​adolescent inpatient unit in Pittsburgh, sat in his office looking through his caseload. He had 12 patients, ages 10 to 17, half of whom had been admitted to the hospital for attempting suicide or for wrestling with ongoing thoughts about it. Some had psychotic disorders or behavioral problems. Most would stay in the hospital for several days to a couple of weeks.

By 9 a.m., Bender was headed to a conference room to join his team — a psychiatric nurse, a social worker and a psychiatry resident — and to hear updates about his patients. Two colleagues, also psychiatrists, covered another 20 or so patients. And still, despite a need for mental health care that has been rising for years, only two-thirds of the beds in Bender's unit at Western Psychiatric Hospital, which is part of the University of Pittsburgh Medical Center, were full. U.P.M.C., like many hospitals, simply lacked the staff to treat more children. Too many nurses, aides and other personnel had quit since the pandemic. Overwhelmed by the work, they had retired, sought higher paying jobs or found different careers altogether.

Bender's caseload that day included a 15-year-old boy who said he would kill himself after his parents, furious, caught him smoking weed. He was convinced his parents hated him. "Kids make threats and say things or do crazy things like that all the time, but not every parent brings them to the hospital," Bender said to the team, wondering why the child was admitted. Then the psychiatry resident told Bender more of the boy's story: He had not been eating or sleeping much, he had been cutting himself (a risk factor for suicide) and he showed little interest in anything, including his friends. His parents found him a therapist, who suggested he try antidepressants, but he resisted; he worried that meds would blunt his emotions. During rounds, about an hour after the conference-room meeting, Bender asked the boy what he imagined his life to be like five years from now: "All the worst things" is how Bender characterized the boy's response to the team.

Suicidal children are caught in a vortex of pain, and those around them are often unsure how to respond. Some pediatricians, as well as therapists, school counselors and others, lack the training to best help a teenager who reveals suicidal thoughts, leaving parents to wonder what to do. At what point do you take your child to the hospital? What if they refuse to go? If they have attempted suicide, do you consider residential care in a facility, where children live for weeks or months at a time? What else can you do to protect them? How do you know they won't die the next time? You lock up your medications, your kitchen knives, your guns if you have them. You find a good therapist, if you’re lucky. But a teenager can always find a way. What alarm system, safety locks or rules guard against a desperate child's resourcefulness?

And the numbers of teenagers — in particular, girls — who are in despair about their lives is surging. Three out of five teenage girls felt persistent "sadness or hopelessness" in 2021, the highest rate in a decade, according to a Centers for Disease Control and Prevention survey released this year. And almost one in three girls (double the rate for boys) seriously considered attempting suicide; more than one in 10 girls actually tried to do so. (Though suicide rates among boys have long been greater, their feelings of sadness or hopelessness haven't increased nearly as significantly.)

Bender's cases that day included a teenage girl who arrived on the unit a few days earlier after she tried for a second time to kill herself by attempting an overdose. (Bender never revealed the names of his patients to me.) Her parents told a psychiatry resident at the hospital that they were shocked; the suicide attempts seemed to come out of the blue. But the girl said she had had thoughts of taking her own life since fifth grade. She told the resident that a romantic breakup had been the precipitating factor. Her parents didn't even know she was in a relationship. Two attempts in one year worried the team. Bender and the resident wanted her to enroll in what's known as a partial hospitalization program, which runs six hours daily, five days a week and includes one-on-one therapy, group sessions with other teenagers and weekly appointments with a psychiatrist. The first time she was hospitalized after a suicide attempt, months earlier, Bender's team recommended the same program to the family.

She never went. The social worker explained that the family had no health insurance and would have to apply for Medicaid. They also didn't have transportation to take their daughter to treatment. Bender suggested family-based therapy, in which therapists come to the home, as a start. "Is there any family therapy we can refer her to?" he asked the team. "Because I’m always hearing there are no openings."

A couple of hours later, Bender met with a third-year medical student, who had interviewed the teenager. Bender explained that the girl was fixated on being discharged: "She has one goal — to get out — and you’re in her way. What's truly at the root of that? You are never going to get the story from her. Go through the chart. Did you notice when I walked around the table? She followed me and couldn't turn her back on me." To Bender, her vigilance suggested a history of trauma. And that only led to more questions: Did her parents have mental-health or substance-use issues? Did she have a history of sexual or physical abuse?

Bender was reminded of another adolescent who was hospitalized a few months earlier, during the first day I spent with him on the unit. The teenager was nonbinary and had been to Western Psych multiple times, most recently after a near-fatal overdose. The mother was considering a residential facility that treated children for suicidal thoughts and attempts, among other things.

At the time, Bender and a child-psychiatry fellow discussed the role that social media can play in enabling teenagers to act on their suicidal impulses. Then the fellow confessed that this case kept her up at night. "I don't know if residential for six months is different than here for two weeks," she told Bender. "But I get it. If it's my kid, I want to put them in residential for safety."

Bender gets it, too. "Everyone wants to keep the kid wrapped up and protected at all times," he said. "Maybe we can prevent a suicide by keeping them in the hospital, but maybe we can't." Bender warns parents about the risks of isolating children from people they love, including family members (though some chronically mentally ill children, including those with deeply dysfunctional families, may need more intensive care outside their home). "You can end up perpetuating the issue, where the kid feels progressively less seen, less heard," he said.

Experts cannot reliably forecast when someone will attempt suicide. In one prominent study of people who killed themselves, one-third of those who were screened the month before their deaths denied having suicidal thoughts at that time. "We don't know if they weren't truthful or if it came on quickly," says Dr. David Brent, a psychiatrist at the University of Pittsburgh School of Medicine and one of the country's leading experts in adolescent suicide. "Even if you can identify who is at risk, you can't very well predict when they are at risk."

And hospitalization can do only so much: It is short-term, designed to stabilize children and then discharge them, ideally into outpatient treatment. "We’re going to discharge at the end of next week," Bender told his team. He pointed out that the teenager seemed motivated to get better. But he acknowledged: "It's a risk they could kill themselves. It's the limitation of this place."

Bender, like so many pediatric and mental-health workers, finds himself on the front lines of a crisis of despair among adolescents, one that affects numerous parts of the medical system. Visits to emergency departments for children with psychiatric problems has climbed a startling 8 percent each year on average from 2015 to 2020, with suicide-​related and self-harm visits outpacing those for all other mental-health problems.

There aren't enough therapists and psychiatrists to meet the demand. The United States has only 14 child-and-adolescent psychiatrists for every 100,000 children — there are more in urban areas, fewer in rural and underserved ones — and wait times to see them can stretch to months. Pediatricians have responded by prescribing antidepressants and other psychiatric medications for children who might otherwise have relied on psychiatrists. In recent years, a growing number of pediatricians began calling U.P.M.C.'s TiPS line, a service that offers primary-care providers access to child-and-adolescent psychiatrists, according to Dr. Abigail Schlesinger, the clinical chief of child-and-adolescent psychiatry at U.P.M.C. Doctors are calling not only to ask how to prescribe psychiatric meds; they are also seeking advice for children with mental-health problems or who are thinking about suicide. They need help getting children into services. Some admit they feel at a loss. They have been considering retiring.

Bender got into the field — in addition to psychiatry, he trained in psychodynamic therapy, a form of in-depth talk therapy — in part because he was the teenager whom friends confided in, and he never forgot how life can feel out of control when you are an adolescent. He wanted a career that allowed him to help children as much as possible by prescribing meds and providing therapy.

Bender, who still has a boyish face at 35, wears his hair neatly combed and prefers plaid shirts (he never wears a doctor's coat). He's a horror-movie fan: His office décor includes a poster from "Halloween" and small figurines like Pennywise, Wolf Man and Stripe from "Gremlins." With his patients (who don't see him in his office), Bender plays the role of curious, open-minded confidant. By the time he gets to them, some children are, as he put it to me, "so done" — frustrated by school, parents, on-and-off-again friendships, romantic relationships, their lack of control over much of anything, life. "They are mad, so mad," he says. One threw apple juice in his face; two girls threatened to kill him after they said they found his address on the internet. "I tell kids, please hate me if you need to," he says. "I prefer you hate me instead of your parents."

His goal is to understand how it feels to be them, not to tell them what they need to do. "When you can't make sense of your despair, I can make sense," says Bender, who has won several teaching and clinical-care awards. "Not ‘expert’ sense, but a realistic sense of what may be going on. I can help them feel contained and engage them. Or not react in the same way as their family. I’m not going to understand everything while they are here. But we can find a closer gray about what the real story is. And, hopefully, help parents do so, too."

As he talked, more children were waiting at the hospital's Psychiatric Emergency Services, six floors below. The PES (pronounced Pez) is the first stop when children and adolescents come to Western Psych's emergency department after passing through security and handing over their phones and bags. To fill out forms, they have to use soft, bendable plastic pens, so they can't harm themselves or others. (For the same reason, the bathrooms’ metal toilets have nondetachable seats.) TVs play cartoons, cooking shows, Hallmark movies. The only available phone is attached to the wall. Patients often spend hours in one of two pediatric waiting areas, sometimes wearing hospital gowns after having been transferred from another medical center. They sit in the blue-and-orange plastic chairs around a table with board games or in leather chairs that fold out to become single beds. Some patients stay overnight — or several nights — when Bender's unit cannot accommodate them.

Psychiatrists at PES interview children and their parents (or other caregivers) separately, to figure out if the patients needs to be admitted or if a referral for outpatient care, which can include crisis services, will be enough. Most teenagers who experience suicidal thoughts don't need to be hospitalized and most don't kill themselves (about 2,800 did in 2021). Psychiatrists have to weigh the possible protective factor of admitting a child against the reality of limited beds and the fact that hospitalization can make anxiety worse, which can drive adolescents away from mental health care altogether.

Medical professionals use the word "suicidality" to refer to a range of thoughts and actions, from passive death wishes, like the desire to go to bed and not wake up, to more active thoughts and, at the most extreme, suicide attempts and death. Though we know a lot about some causes of suicidality — mood disorders, child abuse, substance use — experts don't understand why the numbers have been rising, on the whole, over the last decade. Some blame social media, which can both deprive children of sleep — the lack of which is associated with increased suicidal thoughts — and increase loneliness and feelings of being left out (even as it offers helpful communities for children, especially those who feel marginalized). Since 2020, the pandemic has likely been another factor.

Systemic conditions can also fuel anxiety, anger, dread and, in turn, suicidal thoughts and actions among particular groups — Black children facing trauma and persistent racism, for example, or trans children forced to use the wrong bathroom for them at school and made to feel ostracized, unseen and alone. Rates of suicidality in both populations have increased in recent years. "Ignore the social and family context at your peril," says Brent, who has tracked the rise in adolescent suicide for years.

"It's hard to be in this field," he says, "and watch things getting worse."

Salena Binnig spends most of her working hours trying to help teenagers feel understood and well enough that they don't try to hurt or kill themselves. She is one of 10 therapists at U.P.M.C.'s STAR Center, which was co-founded by Brent 37 years ago. Patients arrive there via various routes, including a referral from a therapist, a psychiatrist or Western Psych. Parents, too, call STAR (which stands for Services for Teens at Risk) to make intake appointments for their children.

Binnig, who is 32 and has worked at the center for four years, has an air of unassuming confidence and a broad smile. In addition to her regular appointments with patients, she sometimes checks in with them throughout the week, especially if they have been harming themselves or mentioning thoughts of suicide. She fields voice-mail messages and email from worried parents. She also runs an intensive outpatient program, known as an I.O.P., for college students and teaches a weekly class for parents to explain what their children learn in an I.O.P. In her leftover time, she occasionally talks to school counselors managing high-risk students.

On a Monday afternoon earlier this year, I met with Binnig and her colleague Layne Filio in Binnig's office during a lunch break. Each had been an intern at STAR, which is one of the few comprehensive youth suicide-prevention centers in the country.

During one of the worst periods in the pandemic, in the fall of 2020, Binnig's typical caseload of 15 to 17 patients climbed to 29, several of whom she worried were at a high risk of suicide. For her and the rest of the staff, the responsibility was (as it continues to be) enormous. Sometimes they have had to take a child directly from a therapy session to the Western Psych's emergency department, which is several blocks away.

"In private practice," she said, "you can just shut down your practice and say you’re full. We don't do that." Around the country, in fact, many therapists do have long waiting lists or have stopped taking new clients. But at STAR, the mission, Binnig said, is to do its best to meet demand, especially for high-risk teenagers. The staff also prides itself on evaluating adolescents quickly. And though the wait list to see a therapist reached six weeks at one point during the pandemic, that was shorter than at many places.

Filio, who now works in a clinic for families and children, is often assigned suicidal children because, she said, "everyone knows I’m not afraid of them." Filio is 32 with long dark hair and several tattoos. On her arm there are images of drawings by Shel Silverstein, the children's book author, and, on one finger, three dots ("like Beyoncé," Filio said), and two small lines on another, a symbol supposedly used by hobos in the Great Depression to mean "the sky is the limit." She told me that the hardest stretch in her career took place last fall, during the week I first met with her. Two of her adolescent patients had been hospitalized after suicide attempts, and her concern about one of them in particular was causing her to lose sleep. The girl had just made her fourth attempt and had already gone through an intensive outpatient program. She and Filio had worked on what's known as a safety plan for suicidality — in which, among other things, the girl listed coping strategies that might help if she felt herself entering a downward spiral. But the girl didn't look at it later. "She does great one week and then feels awful in the moment and doesn't know how to self-regulate," Filio told me. Even though the girl felt a connection with Filio, Filio knew she wasn't always telling the truth.

That was just one case. Filio had so many others, including Black and L.G.B.T.Q. kids who were suffering from systemic harms. "We are holding people's trauma for them, until they are able to hold it for themselves," she said, "and that weighs on me. Incredibly."

Filio tries to find ways to relate on a personal level with her patients. For years she has been learning about Fortnite and talking to many of her patients about the online game. She sometimes tells teenagers about her own struggles with depression to destigmatize their feelings. And if a child who seems to need medications is wary about taking them, she reveals that she takes meds for depression.

"Part of how I do therapy is to meet them where they are and take them at their word," she said. "I don't have any other options. I’m trying to understand what they are trying to say rather than tell them what they are trying to say, which is what it felt like when I was a kid."

Good therapists can be any age, of course, but younger therapists like Filio and Binnig can help suicidal children feel "this person gets me," says Jonathan Singer, a suicide expert and professor of social work at Loyola University Chicago. "A key experience of being suicidal is a feeling like you don't have a place in the world, you are a burden. You’ve failed in some fundamental way."

As Filio and I sat in a coffee shop last fall, not far from the house where she lives with her partner and dog, she looked over her list of 50 clients. "Five, six, seven, 12, um, 19," she said, totaling how many grappled with suicidal thoughts. About half of the group were L.G.B.T.Q. Several of them had parents or other adults in their lives who wouldn't use their pronouns, refused to accept their sexual identity or suggested that being trans or gay was a "stage." In one case, a 13-year-old girl wanted to join an L.G.B.T.Q. support group that Filio had started, but because of her age, the girl needed parental permission. After Filio raised the prospect with the mother in an online meeting, the mother's screen went blank. Filio never heard from her or her daughter again. According to the Trevor Project, which provides crisis services for L.G.B.T.Q. youth, children whose families don't support their identity or who are in schools or communities that don't accept or affirm L.G.B.T.Q. people have higher rates of attempted suicide.

Families can increase the likelihood of suicide attempts, too, by rejecting the standard advice about locking up medications and guns. A 1993 study by Brent and his colleagues found that the biggest risk factor for suicide by adolescents who had no identifiable psychiatric disorder was having a loaded gun in their house. One 16-year-old girl told me the only reason she's alive is because her parents locked up their medications.

Some of the parents Binnig works with don't fully buy into the program — they don't want to lock up their meds and guns, they don't like how much therapists check in with their children, they don't believe in mental-health treatment. Binnig is known among her colleagues as the "queen of irritable parents," because she is empathetic with parents and stays calm when they are anxious, unhappy or angry. She also tries to help parents understand why their teenagers refuse to go to school, turn in homework late or cut themselves — and that there are more supportive responses to those problems than grounding their children or taking away their phones.

Then there are the parents who are so anxious and desperate for someone to alleviate their child's pain that they blame the therapist when she can't pull it off. When Binnig recommended to one father that his daughter might need hospitalization, in addition to continuing her therapy, he told Binnig she was incompetent.

Binnig never dissuades parents from telling her what's going on with their children — indeed, she needs to know if they are harming themselves. But sometimes parents call or email Binnig with small updates: She was in the bathroom last night crying about her boyfriend. She is spending too much time in bed. She had a fight with her best friend at school. Binnig understands the stress the parents feel, but she reminds them that she is the child's therapist, not theirs. " ‘I need your kid to be telling me these things," she explains to them. " ‘I don't want to keep constantly saying, ‘Your mom told me this.’"

As Binnig's colleague James Russell puts it, "Therapists aren't superheroes." Russell's office is just down the hall from Binnig's, and sometimes she or other STAR therapists refer clients to him for family therapy. As one of the only Black therapists at U.P.M.C., he is in high demand by families who might be wary of white therapists or of therapy in general, given the long history of racism in psychiatry and psychology. (Among many other failings in the field, diagnoses of schizophrenia and conduct disorder are disproportionately given to Black children.) "We call it ghosts of therapy past," Russell says, referring to the negative experiences that families have had with health care professionals. "We see it a mile away when we get these folks. Some damage has been done, and we have to repair."

Russell, who is 41, became interested in therapy after a college adviser suggested he study psychology. His family didn't talk about strong emotions or the impact of trauma on their lives: "It didn't feel natural or safe to do so," he says. He also didn't believe therapy was for people who looked like him or experienced the world as he did. Still, the psychology classes he took intrigued him and after college, and while getting his master's degree, he worked various mental health care jobs before landing in family therapy.

But in 2020, he decided to reduce his patient caseload and begin training and supervising U.P.M.C. staff members. Early that year, his father-in-law died. Then, in May, George Floyd was murdered by a police officer. Part of him wanted to go to protests; another part of him feared, he says, that "it could happen to me." He also thought he could be arrested, which would leave his patients without a therapist. Months later, his own father became gravely ill. He would be on a call with his family discussing whether to remove him from life support and then have to go directly into a therapy session at which a client might start talking about her own father. He would briefly lose himself in thought. At the same time, the pandemic was raging. "It's one of the hardest times in history," says Russell, whose father died later that year. "And you have a mission. But then you think, Wait, is this right for me after all, or is this exactly what I expected? You’re working to make sure everyone's OK, but you don't have time to process your own loss and grief. With frontline staff, it's all well and good if things are going well for us. But life stressors hit us, too."

That same fall, in 2020, as Russell wrestled with family losses and as Binnig's caseload ballooned, a 15-year-old girl named Sophie began attending STAR, where Binnig became her therapist. Sophie quickly came to trust that with Binnig, unlike with her previous therapist, she could confess to having suicidal feelings or cutting the back of her thighs without panicking that she would be "sent away." She liked that Binnig took her worries seriously without rushing to try to fix them or responding like an authority figure. (Binnig would not disclose details about her or any of her clients for privacy reasons. A U.P.M.C. psychiatrist put me in touch with Sophie.) She didn't say, as others had about her cutting, "Why would you do something like that to yourself?" That only made Sophie feel worse.

Sophie (who asked me to use her middle name to protect her privacy) is a thoughtful, emphatic person, with pale teal eyes. An animal lover — her bed is covered with stuffed animals — she makes her mom stop the car so she can take dead squirrels, raccoons or possums from the street and give them a proper burial in her backyard.

But by late summer 2020, before she was seeing Binnig, Sophie could barely get out of bed. Her grades had fallen from As to Fs. Though her thoughts of suicide were mostly passive, her panic attacks had grown more frequent — small ones arrived every couple of days; large ones, every few weeks. A small conflict or feeling of anxiety would lead to painful memories and then ruminations in endless loops. Her body shook, her teeth chattered, she drooled and she often couldn't speak. She felt as if she was losing her mind. She didn't care if she lived or died. She just wanted the agony to go away.

When her mother couldn't find a psychiatrist to see her — the ones her mother called weren't accepting new patients or had six-week waiting lists — she and her ex-husband took their daughter to Western Psych's emergency department for an evaluation. The psychiatrist referred Sophie to STAR.

Days later, Sophie had an intake session with a STAR staff member, during which they created a safety plan. The next week, when she first met with Binnig, they continued to talk about the plan, which included leaving her room if she was heading into a cycle of despair; playing with her two pet rats; and listening to a playlist she had created to distract her, with songs like "Chop Chop Slide," by Insane Clown Posse; "Juicy," by Doja Cat and Tyga; and "Obsessed," by Mariah Carey. The plan also listed whom Sophie would call when she felt out of control: her mother, then two local crisis programs where she could talk to someone.

Binnig encouraged Sophie to join STAR's intensive outpatient program, too, where about 10 teenagers met for a few hours with therapists, three afternoons a week. The I.O.P. is less group therapy than a skills workshop. The program centers on dialectical behavior therapy, or D.B.T., which was developed over the past five decades by a psychologist named Marsha Linehan, who was suicidal herself. Studies suggest that D.B.T. reduces suicide attempts in adolescents experiencing high levels of suicidality. Sophie and the other adolescents learned D.B.T. techniques, including how to identify feelings of anxiety, depression, anger and disappointment and put those emotions into words. The patients can write down their feelings about suicide, but they aren't allowed to talk about them in depth with others in their sessions, only with a therapist — teenagers, more than any other group, are vulnerable to the contagion effect in which a peer's suicide can lead to copycat attempts.

Therapists encouraged Sophie and the other teenagers to practice short-​term goals — complete a school assignment, engage more with friends, exercise — and to understand that there's more than one way to see a situation or solve a problem, something Binnig reinforced in her sessions. And on a typical day they did a guided mindfulness exercise and worked on cognitive-behavioral-​therapy exercises like avoiding negative self-talk to challenge their thinking about their depression, anxiety or suicidal thoughts.

The exercises aren't always immediately effective — Binnig has had to send some patients to the hospital even after they have completed an I.O.P. more than once. Suicidality can also be like a wave that subsides only to return suddenly as an untamable swell. So it was for Sophie. After stretches of feeling stronger in 2021, that summer Sophie's on-again-off-again girlfriend once again broke up with her. Sophie was struggling with her dad and stepmother and her feelings of abandonment. She had few friends; she had lost interest in jewelry making and playing music. The breakup felt like the final blow. As she listened to her girlfriend on the phone, Sophie began hyperventilating and sobbing in heaves; her hands and toes twitched. She wasn't sure where she was.

She hung up the phone and poured a bunch of pills into her hand. But just then her stepsister walked into her room. It was like cold water splashing in her face, awakening her. She put the pills back in the bottle.

Sophie was in family therapy at that point, and the therapist encouraged her to attend a program similar to the I.O.P. but more extensive — six hours a day, five days a week. Before she got off the weekslong waiting list, she wrote in her journal that her pain felt like "a never-ending cycle and I’m losing my mind, like life is really pulling my final straws. I feel like I’m beyond coping now."

But once she started the program, Sophie felt relieved to be among people who battled similar issues. After the third day, she wrote in her journal: "Everyone here is super nice and full of a beautiful, unique mixture of struggles, talent and personality. I hope to cross paths with everyone again, someday. Everyone here deserves nothing but kindness and relief."

Still, that night she cut her thighs to distract herself from her anguish. But she also downloaded an app that helps users track self-harming behaviors and get support. And every weekday, for almost a month, she returned to the program, where she liked feeling that no one was judging her. When it was over, she resumed her weekly appointments with Binnig. Her progress was jagged for a long time, but with the help of Binnig and the coping strategies she learned, Sophie started to believe her identity extended beyond being a depressed person. She could imagine a future that would have felt impossible two years earlier. (She recently got into college with almost a full ride on tuition.) Her mother, who had become overwhelmed when Sophie wasn't getting better, learned to stop trying to control parts of daughter's life. She backed off making what she thought were helpful suggestions for Sophie — meditate, read self-help books, eat more, exercise — which Sophie just batted away.

It's a difficult balance for worried parents. But as Binnig told me, those who do best by their children take their problems seriously while managing to not hover over them. Ultimately, she said, "getting better has to be the child's own process."

There is evidence that less intensive and less expensive therapeutic interventions against suicide might help children, at least those at the highest risk and, by extension, put less pressure on the medical system. For a study published in 2001, more than 800 patients in San Francisco who were hospitalized for suicidality or depression and who declined follow-up care were assigned to two groups: One had no follow-up contact and the other received periodic, typewritten letters from a health care worker who had interviewed them. The letters were brief but expressed concern and a desire to keep in touch. "It has been some time since you were here at the hospital, and we hope things are going well for you," a typical letter read. "If you wish to drop us a note we would be glad to hear from you." Patients in the contact group received eight letters the first year, then four letters for several years. Within two years of leaving the hospital — the span of time during which suicidal patients are most likely to kill themselves — the group that received letters was half as likely to die by suicide as the control group. Even several years later, the rate stayed lower. Since then, research has suggested that apps focused on suicide prevention may also help. Studies funded by the National Institute of Mental Health are investigating the efficacy of digital interventions that encourage children and teenagers, upon discharge from the hospital, to gauge their suicidal feelings and gives them strategies to help; another provides support for parents and tips about safety planning.

Better, of course, would be reaching children far earlier. In the last two years, during which the American Academy of Pediatrics and other national children's organizations declared a "national emergency" in child-and-adolescent mental health, President Biden's administration began devoting hundreds of millions of dollars to mental health care. Many states have created suicide-prevention programs and efforts to connect students and families to community social services. We already know that schools that teach coping skills and ways for children to receive help when they are depressed or anxious reduce substance abuse, aggression and jail time, along with suicidal thoughts and behaviors.

But for now, therapists and psychiatrists contend with an unceasing flow of children. "There are people who do this for years and years, but most of us leave after a couple years," Binnig says, referring to STAR therapists. Many go into private practice, where they might treat lower-risk children and have more flexibility and the opportunity to make more money. Binnig isn't sure what she will do. She loves her team; she's invested in her patients, but she thinks about a hard day not long ago with a patient who resisted therapy and felt deeply hopeless and sad. She told Binnig that she worried she might attempt suicide, but she didn't want to go to the hospital. She had received inpatient treatment before, and it was lousy. Binnig and another clinician called her parents, took her to the hospital and waited with her so they could be part of the evaluation. That evening, Binnig didn't get home until 9:30.

After hard days like that, Binnig usually collapses on the couch and stares at the TV with the volume low. "My husband gets it," she says. But she is expecting their first child in August, and that gives her pause. "I wonder when I have my kids, will I be emotionally able to do the work that I do, and then come home to my kids and still have an emotional battery left?"

Bender knows the feeling. After a decade in this field, he's good at compartmentalizing, but it has been impossible some days not to let cases get to him. Last year, for example, when his team was worried about the nonbinary teen who overdosed, he consulted with the child's outpatient psychiatrist. "I have that feeling of, I’ve got to figure this case out," he told his team. "Even though frequently you can't in this setting." While the teenager was hospitalized, Bender worked each day to understand their story and perspective. He regularly checked in with them: "Does this feel like we’re talking about things that matter?" Yes, they said. They also noticed how invested their mother was in family meetings, how she kept showing up and not giving up.

Bender doesn't know how the teenager is doing now. When he discharges children, he is hopeful that something from their therapeutic work sticks. (As far as he knew, only one teenager who stayed on his unit later died by suicide.) Still, some children show up in the hospital over and over. And Bender has learned not to be surprised when he sees them; patterns are not so easy to break.

He has grown more patient since he was a psychiatry resident, when he often felt hopeless. No treatment was enough: not meds, not cognitive-behavioral therapy. He felt that he couldn't save children from their agony. He became mad at the system, at the children themselves. "I felt like: What the hell is this? Nothing works," he says. "I had to embrace my limitations, my helplessness. I only could really do this work when I started to ask: What am I capable of? Because if you feel like you’re going to ‘fix’ kids, really fix? Then you’re going to end up hating your work, because you’re going to end up disappointed."

Instead, he shifted his views about the work and his impulse to safeguard suicidal children at all costs. He began focusing on making them feel "seen and human," as Bender puts it. "If I can help a kid feel understood and help parents understand their kids," he told me, "that is treatment."

If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

Maggie Jones is a contributing writer for the magazine and teaches writing at the University of Pittsburgh. She was a senior Ochberg fellow at the Dart Center for Journalism and Trauma. Sophi Miyoko Gullbrants is a Japanese American artist based in Brooklyn. Their work explores human connection and intimacy in relation to food, sex and mental health.

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