Working with Suicidal Ideation in Outpatient and IOP Care
September is Suicide Prevention Month. Suicidality is a common experience for clients with eating disorders, whether due to underlying trauma, other co-occurring disorders, or as a result of the emotional and physical effects of an eating disorder. Adults with a history of eating disorders are 5-6 times more likely to attempt suicide compared to the general population (Udo, 2019; Conti, 2017). Over 40% of adults diagnosed with anorexia or bulimia nervosa report suicidal ideation in their lifetime (Pisesky, 2013). Eating disorders commonly co-occur with other disorders and life experiences that carry a high risk for suicide, including single incident and complex trauma, substance use disorders, and mood disorders (Tidemalm, 2008; Haukka, 2008).
Suicidal ideation (SI), or suicidality, exists on a spectrum, from passive fleeting thoughts such as “I wish I weren’t here” to chronic and active suicidal ideation, including some intent, plan, and/or means, that must be closely and consistently tended to. Navigating SI in outpatient and IOP levels of care requires a high degree of trust and communication between clients and clinicians, but it is possible, and advantageous, to avoid carceral or coercive responses.
For many, the fear of consequences for admitting thoughts of suicide prevents them from being honest with their clinical teams until the feelings are so unmanageable that it becomes an emergency. If clients feel safe enough to express suicidality and create honest, realistic coping plans, they are more likely to open up about other difficult feelings and discover the underlying patterns and beliefs. Crucially, avoiding responses such as hospitalization or discharge to a higher level of care allows clients to maintain ties to those things that are life-giving, such as family, friendships, jobs, hobbies, and pets. In the same way that outpatient and IOP aims to allow clients to recover in their natural environments, we work with clients to create safety in their normal lives wherever possible, which also builds strength and confidence.
These factors can help strengthen the therapeutic relationship and create openness and safety when working with suicidal ideation:
1. History of SI and protective factors.
Gathering a history of a client’s suicidal thoughts, actions, and plans is the basis of working collaboratively around suicidality. Speaking openly and fully to these experiences also reduces shame and secrecy. Additionally, noting protective factors (for example: close supporters, community involvement, and spiritual beliefs) highlights a client’s values and can guide both their motivation and plan for practicing safety. As much as a client can tolerate and feels safe answering, understanding potential triggers and past patterns informs warning signs and best practices.
2. Safety planning.
Safety plans should be created early and thoroughly in treatment. The best course of action when a client is dysregulated and experiencing suicidal ideation is one that they themself have crafted.
Create this plan when a client is feeling regulated and reflective. It should include resources, protective factors, and coping skills. This is also a chance to check in with the client about what actions they would like the therapist to take and when. Therapists should be open from initial intakes about their professional parameters around SI, including expectations of safety and mandated reporting. A safety plan is a living document that evolves as the client identifies new resources or changes their mind about what is helpful.
Questions to consider: What matters to them? Who can they turn to? What are early warning signs that things are feeling unmanageable, and what are signs that it might be developing into a crisis? A thorough history informs this as well: what has been protective for the client in the past? What hasn’t worked? How do they want to be helped and witnessed?
3. Trust is the basis of the therapeutic relationship and it is the greatest asset when working with suicidality.
Many clients have been subjected to punitive or fearful responses to emotional crisis. To successfully communicate about suicidal ideation and work effectively, the therapeutic relationship must be one of honesty, compassion, and bravery. Building trust takes time, and therapists jumpstart this by speaking openly and non-judgmentally about suicidal thoughts. When clients know that these conversations are welcome, and are informed about a therapist’s approach to suicidal ideation, they can begin to use the space as a resource.
Simultaneously, resourcing for emotion dysregulation begins to build a client’s coping skills toolbox. Clients may need to experiment with coping skills and test what is effective for particular situations and levels of distress. Practice is essential for these skills to be accessible in a time of crisis, and a few well-worn skills can go much farther than an endless list of untested skills. Adapt a safety plan as needed to simplify, clarify, or add the most effective approaches.
4. Collaboration and communication help both client and therapist feel grounded in the strength of the relationship and a client’s plan for managing crisis.
Clients might employ a variety of behaviors to manage distress that are traditionally seen as “maladaptive” or destructive, but serve a very functional purpose. Open dialogue about self-harm, eating disorder behaviors, substance use, and other impulsive behaviors can help therapist and client track changes in mood and risk tolerance. Curiosity, rather than pathologizing, honors a client’s autonomy and efforts to survive. If these behaviors can be treated as information, therapeutic work can focus on moving towards a client’s values and establishing safeguards where possible. Tracking these behaviors, along with the co-occurrence of suicidal ideation, can help predict and prevent crises that might occur if clients fear being punished or pathologized for their survival tactics.
5. A client’s values and goals are the foundational guideposts for working with suicidal ideation.
Identifying these early in treatment and referencing them frequently gives therapist and client something to move toward. If a client feels therapy is based primarily on those things they need to move away from, the process can feel alienating and frustrating. Highlighting a client’s values also checks biases from the therapist by resetting the therapeutic lens: what constitutes an achievable goal, a realistic safety plan, and a whole life is for the client to define. Therapists complement their clients by being flexible and encouraging while holding the motivations and boundaries established by the client when they might be too dysregulated to hold this for themself.
Clients and clinicians deserve for no topic to be off limits. The therapeutic alliance in outpatient and IOP levels of care can be transformative for clients experiencing acute and chronic suicidal ideation. By approaching the topic with a spirit of openness, curiosity, and respect, we can dispel feelings of shame and create space for healing.
References:
Udo, T., Bitley, S., & Grilo, C. M. (2019). Suicide attempts in US adults with lifetime DSM-5 eating disorders. BMC Medicine, 17(1). https://doi.org/10.1186/s12916-019-1352-3
Conti, C., Lanzara, R., Scipioni, M., Iasenza, M., Guagnano, M. T., & Fulcheri, M. (2017). The Relationship between Binge Eating Disorder and Suicidality: A Systematic Review. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.02125
Tidemalm, D., Långström, N., Lichtenstein, P., & Runeson, B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ, 337(nov18 3), a2205. https://doi.org/10.1136/bmj.a2205
Haukka, J., Suominen, K., Partonen, T., & Lönnqvist, J. (2008). Determinants and outcomes of serious Attempted suicide: a nationwide study in Finland, 1996-2003. American Journal of Epidemiology, 167(10), 1155–1163. https://doi.org/10.1093/aje/kwn017
Pisetsky, E. M., Thornton, L. M., Lichtenstein, P., Pedersen, N. L., & Bulik, C. M. (2013). Suicide attempts in women with eating disorders. Journal of Abnormal Psychology, 122(4), 1042–1056. https://doi.org/10.1037/a0034902
