NEDA Meeting Highlights

Working with Patients at Risk of Suicide

Reprinted from Eating Disorders Review
March/April 2012 Volume 23, Number 2
©2012 Gürze Books

The statistics are sobering: Suicide mortality rates among patients with anorexia nervosa (AN) and bulimia nervosa (BN) are much higher than rates among the general population. AN has the highest suicide rate of all psychiatric disorders. And, according to two therapists at the October 2011 NEDA meeting in Los Angeles, a sizeable number of clinicians never ask patients about suicidal ideation and many are uncomfortable even approaching the subject.

Melissa Freizinger, PhD, and Caroline Balz, LMHC, said that 1 of 5 psychologists will lose a patient to suicide, and that suicide is a frequent cause of malpractice suits. Dr. Freizinger is Director of the Intensive Care Outpatient Department, and Caroline Balz is a mental health counselor, at Walden Behavioral Care, Walden, MA. The two stressed that clinicians are neither expected to predict nor to prevent suicide, but they are expected to identify patients who are at increased risk for suicide and to take steps to protect them whenever possible.

Freizinger and Balz noted that suicide rates among women with comorbid alcohol use disorders are 57 times greater than the expected rates among healthy women (Herzog and Luczaj). Suicidal AN patients also frequently turn to extremely lethal measures to attempt to take their lives, including burning, hanging, and jumping in front of trains. Another sobering fact is that suicide among eating disorders patients occurs not only more often in the later stages of the disease but also during times of remission. And, they added, 6% to 10% of those who attempt suicide will succeed.

According to the two therapists, the topic of suicidal risk is challenging for many clinicians. This reluctance to deal with threatened harm is natural, they continued, because we all experience distress around the subject of suicide and some denial may be functional. The speakers asked clinicians in the audience to write down their responses to two questions: “Are you asking your clients questions about their thoughts/intentions about suicide?” The second question was, “If you aren’t asking these questions, what might be getting in the way?”

Some Risk Factors for Suicide Attempts

In recent years, several risk factors for attempted suicide among persons with eating disorders have been identified. Red flags should go up when the patient has the following risk factors:

  • Impulse control disorder;
  • An extensive treatment history;
  • Earlier onset of symptoms;
  • More dissociative symptoms;
  • A history of major depressive disorder and higher severity of depressive symptoms;
  • Characteristics that correlate with suicide attempts, including a history of sexual abuse, laxative use, and drug, alcohol, or tobacco use;
  • Character traits including impulsivity, perfectionism, and low self-directness;
  • Among AN patients, older age and lower body weights;
  • Among BN patients, co-morbid anxiety or personality symptoms; and
  • A sense of hopelessness about recovery.

What are Risk Factors for Completion of Suicide?

Freizinger and Balz noted a number of risk factors that have been connected to successfully completing suicide, including: alcohol abuse; cluster B personality disorders; duration of illness, spiritual acceptance of death; and social isolation. They also stressed that the more severe the eating disorder, the higher the risk for suicide, and in this setting worsening moods and increasing panic attacks are worrisome.

Opening a Dialogue with Patients at Risk

The first step in assessing a patient’s potential for suicide is to open a dialogue with a patient believed to be at risk by asking the right questions and understanding the role suicide plays in the context of the patient’s value systems and experiences. By validating a patient’s feelings, and “being there in pain” with her, it may be possible to better approach the subject.

Dr. Freizinger urged audience members to be curious about the meaning the patient attributes to ending her life. Some protective factors may be helpful buffers for patients at risk. Family support, the presence of friends, and other significant relationships can be protective, as are the patient’s individual skills in problem-solving and a nonviolent approach to handling stressful disputes. Other factors, including community involvement, a satisfying social life, constructive use of leisure time, access to mental health care and services and even owning a pet can be protective.


Although one commonly used intervention is the use of a safety contract, Dr. Freizinger said no empirical evidence supports the effectiveness of such contracts in preventing suicide, and relying on a safety contract alone is not good practice. Its value is particularly dubious when the patient is impulsive, a substance abuser, or prone to dissociation. Safety contracts also don’t work if the patient isn’t attached to the therapist. Finally, such a contract does not protect therapists from malpractice litigation.

Instead, Freizinger and Balz suggest that a better approach is to focus on developing a safety plan. A first step in helping the patient stay safe is to remove obvious lethal hazards around her. They suggest asking the patient what method or methods she plans to use—the higher the risk, the more active and immediate the therapist’s response must be. The safety plan requires taking measures to delay the patient’s suicidal impulses, and to focus on solving the most immediate problems. If strong urges to commit suicide occur, to whom can the patient turn,in person or by phone? Where is the nearest emergency room the patient can go to, and how would the patient get there in the middle of the night? The therapists suggested increasing the number of sessions and check-ins, explicitly encuraging the patient not to commit suicide, and instead getting her to commit to dealing with the psychic pain, suicidal urges and precipitating stressors by taking a different course of action. The more specifically and concretely this course of action can be worked out in advance, the better.

The dialogue should include questioning the patient about whether she has taken steps toward writing a suicide note, asking if she has any plans for isolating herself, and asking if she has taken any steps against being discovered. If the risk of suicide seems imminent, the therapist should find out how available other people are to the patient today and in the next several days and if necessary take steps to assure that the patient will be escorted by police and/or ambulance if necessary to an emergency room.

Planning Ahead: From Theory to Practice

The authors suggest having an up-to-date crisis planning sheet, and making certain the at-risk patient is carefully monitored between regular sessions. Therapists should also check with the prescribing clinicians or another medical professional to understand the possible lethality of medications the patient is taking.

The speakers also urged clinicians to use risk management techniques for themselves. It is important to take time to examine your own technical and personal competence with managing suicide risk and suicidal behavior, they said. Another suggestion was to keep meticulous and timely records, and to obtain previous medical and psychotherapy records for each patient. They also suggested involving other team members (and the risk management personnel in any managed care company that might be involved) discussions about patients who seem to be at risk.

Freizinger and Balz stressed that therapists need to take care of themselves as well as their patients and should pay close attention to their countertransference in managing these patients. Consultation is a necessity, as is being mindful of one’s overall caseload. Finally, the speakers urged all clinicians and therapists dealing with suicidal patients to “Know your limits.”


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