Suicidality and Eating Disorders: Case Analysis
Volume 6, Issue 2
Sherrie Maher, PhD
Remuda Ranch Programs for Eating Disorders
Jennifer, 35, had long been in denial about her eating disorder (ED). She gave God an ultimatum, “Either take this eating disorder away, or I am going to kill myself.” She knew her ED behaviors were harming her health. But depression had been a lifelong problem and losing weight helped her to feel better. Her ED was the most effective weapon she knew against depression.
During childhood, Jennifer’s father was usually absent. She never liked him. He yelled and hit her and her siblings. Her mother also hit her. Even more wounding was an emotionally invalidating home environment. When she cried, her mother told her, “I’ll give you a real reason to cry.” Her feelings and thoughts were often dismissed with sarcasm. Rarely was she told she was loved, wanted, or important. She learned that trying to communicate her inner life was completely futile.
Her parents’ relationship was far from ideal. Her parents screamed at each other. She sat in silence or withdraw to her room.
Jennifer struggled with memories of early childhood sexual abuse by a babysitter. Her memories of this were fuzzy. However, she clearly recalled telling her parents about it. They did not believe her, but dismissed her report and did nothing.
As an adult, Jennifer’s shame and ill-fated attempts to find love led to bad choices. Each attempt to find a relationship to fill her emptiness ended in more trauma and increased her shame and unmet needs. One particularly painful example was an affair she had with a married man. This man eventually raped her and stalked her. She had become pregnant by him, culminating in an abortion. Now she avoids all relationships with men.
Jennifer had post traumatic stress disorder, struggling with flashbacks and nightmares. She never felt safe, leading to hypervigilance. She had severe panic attacks that began in childhood. Nights were the worst. She began using medication to calm herself and fall asleep. She also began drinking and smoking marijuana to alleviate anxiety and depression.
Prior to her ED onset she experienced a series of difficult losses. Jennifer was unable to grieve or ask for help. The losses exacerbated childhood abandonment fears. At this time, Jennifer contracted the flu and could not eat. She lost weight. She felt good about the weight loss. She realized that dietary restriction alleviated her depression.
Jennifer frequently thought of suicide and had made numerous suicide attempts. She had been hospitalized for several attempts. She had tried to overdose, hang herself, and asphyxiate herself with carbon monoxide. Her most recent suicide attempt was six months prior admission, when she overdosed on prescribed medications combined with those she had stolen.
Jennifer saw suicide as an escape from her life and herself. She felt strongly inadequate and always empty inside. She stated, “I should never have been born.” She felt she was “getting in the way of other people.” This statement was a combination of her true feelings and a means of eliciting nurturance.
Jennifer engaged in self-harm, burning and cutting herself. She said, “It helps bring me back to the here and now in the midst of flashbacks, and to punish myself for being bad.” Self-harm also expressed her rage and was a method she used to avoid suicide. She believed, “If I didn’t self-harm, I would escalate to suicide.”
As a result of numerous, dangerous suicide attempts Jennifer admitted to Remuda on our Suicide Observation Status protocol. Her suicide risk was evaluated regularly and precautions taken to keep her safe. Jennifer completed a self-harm diary card. One function of this card was to help her identify individuals she could turn to if she was experiencing self-harming or suicidal urges. Suicide prevention plans were carefully outlined for discharge, involving friends and aftercare providers as needed.
Psychological testing indicated severe depression and anxiety, and overwhelming needs for attention, support, and nurturance combined with severe trust issues. Her need for and fear of intimacy were both extreme, resulting in a “come here/go away” dynamic. Evaluation revealed extremely unstable emotions that impacted her judgment. Reality was what she felt at any moment. If she felt unwanted, she was unwanted. If she felt hopeless, there was no hope. If she felt fat, she was fat. If she felt accepted by someone, he was the greatest person in the world, but if she felt rejected by him, he was horrible.
Other assessments indicated that Jennifer believed her problems would resolve if she could find someone who completely loved and accepted her. As such, she placed people in parental roles, seeking structure, nurturance, security, and self-esteem through attachments to them. But due to experiences with her parents, she anticipated rejection and abandonment. She typically chose people who would abandon her, or pushed people away through inappropriate behaviors. These tendencies were central in her risk of suicide. She became most suicidal during periods of perceived rejection, often to demonstrate her pain to those rejecting her. Evaluation indicated that Jennifer was unlikely to have insight into this pattern or her contributions to it.
Our culture overvalues physical appearance and sexual appeal as cornerstones of personal self-worth and acceptance. In this context, Jennifer’s body became the focus of her hope to feel worthy and capable of obtaining the relationships she desired. If she looked good—which in her mind meant being thin—she believed she had a chance of acceptance, particularly by a man.
Self-worth and hope were entangled with thinness. Weight gain left her feeling powerless and hopeless and therefore made her vulnerable to suicide. As weight increased in treatment, Jennifer wanted to die. Her suicidality was a real expression of desperation and an attempt to get her providers to back off and let her remain at what she believed was a safe weight.
Jennifer used suicidal statements like a remote control: aiming them at family, friends, therapists, and fellow patients to manipulate these people into meeting her needs. She had never learned to meet her needs in other ways.
Jennifer raged about her parents. Her emotional investment in and focus on her parents was abnormal for someone her age. This situation is sometimes called a hostile dependency, where an individual is both extremely angry with a person and yet extremely dependent upon them. Such individuals vacillate between attacking the person upon whom they depend, and pulling for nurturance. Jennifer reenacted this dynamic with staff. Jennifer would act out to see how staff responded. She pushed boundaries, broke rules, and became argumentative and resistant to interventions. When confronted about her behaviors she would fly into a rage and allude to suicide.
She insisted that the cognitive-behavioral skills she was learning were not working, giving her a rationale for continued acting out. She was challenged to use the skills even if she believed they did not work. In order to facilitate insight into her acting out behaviors, staff used behavior chain analysis (Linehan, 1993). Acting out behaviors, such as her rage reactions with threats of suicide, were traced back to specific events, thoughts, and feelings that had led to them. This method is helpful with patients who have poor insight.
Jennifer’s treatment team determined that a primary task of therapy was to validate her painful past without allowing her to dwell on that past as a reason for not moving forward or for acting out. Such validation was critical. Without it, pointing out Jennifer’s emotional responses and behaviors would have been experienced by her as yet another attack.
In individual therapy, Jennifer switched topics constantly. In response, her therapist validated her fear of focusing on her issues, and noted that switching topics was a coping skill she had learned to avoid emotional pain. However, her therapist educated her that her pain would only be temporarily quenched by this strategy. As Jennifer changed subjects when difficult topics arose, her therapist empathetically pointed out her avoidance. This occurred many times during therapy sessions. Eventually, Jennifer began accepting redirection and even smiled when her avoidance was pointed out to her.
Her treatment team developed a hierarchy of issues to deal with, focusing on suicidal behaviors first, therapy interfering behaviors next, and finally quality of life interfering behaviors. When suicidal or self-harm behaviors arose, her team immediately dealt with these, but was careful not to reinforce them.
In group therapy, Jennifer worked on identifying painful emotions and practiced in vivo relationship skills with other patients. She struggled with another patient who reminded her of her mother. She was encouraged to practice assertiveness with this patient. At first, she oscillated between extreme passivity and aggressiveness, but in time learned the middle-ground of assertiveness. Group therapy proved crucial in that it allowed her to practice the skills she was learning.
Jennifer additionally struggled with substance use and trauma. Through individual therapy and substance abuse classes, she recognized that she used substances when unable to engage in ED behaviors, and vice versa. Jennifer also tackled the initial stages of trauma work. She needed a cognitive-behavioral and emotion regulation skills foundation before exploring the painful trauma issues that drove her back into her ED. For example, her treatment team determined that she should not work on flashbacks until she had skills to cope with them and keep herself grounded. Jennifer often began to restrict her eating when trauma symptoms emerged, so she was coached frequently on what skills could serve as appropriate alternatives for ED behaviors. Eventually she was able to accomplish initial trauma work without engaging in her ED, and she enrolled in Remuda’s trauma recovery class. She progressed slowly but surely in dealing with this difficult issue.
Staff provided a structured, safe environment for Jennifer. They met her acting out behaviors with a neutral therapeutic stance: staff attended to her needs, but minimized reinforcement of her behaviors. Clinicians acknowledged the reality of her past wounds, but focused on helping her to find new ways to deal with those wounds. Through consistency and repetition, Jennifer began to learn how to differentiate between the sarcasm and abusive remarks about her behaviors characteristic of her past, and the supportive feedback about her behaviors coming from her treatment team and intended to help her.
Jennifer adapted to the program’s structure and came to depend on it. In this context, she also renewed her faith in God and began to see God no longer as a harsh and judging parent, but as a benevolent father who accepts her fully and loves her.
Toward the latter part of her stay, Jennifer returned to statements about “people being better off without her.” This was triggered by her upcoming discharge from the structure and relationships of Remuda’s intensive program. Jennifer’s re-emerging maladaptive behaviors communicated that she needed more help with the transition. Thus, therapy focused on helping her come to terms with the eventual separation and loss. Steps were taken to make the transition easier, and to teach her how to tolerate and deal effectively with transitions. Jennifer discharged without incident. She went through some struggles, but was able to begin the next stage of her treatment.
The inpatient environment allowed for stabilization of Jennifer’s out-of-control behaviors and emotions. With stabilization, the process of validation, behavior training, and cognitive work began. Acting out behaviors were seen as opportunities for learning and change. A step-down program then provided the challenge of a life transition. Although transitions had previously led to extreme acting out, this time was different. Jennifer learned that she could survive transitions, and experienced how to deal with them without acting out. The step-down program also fostered more independence, in a less structured but very supportive environment.
Jennifer entered outpatient therapy, where she will continue to replace temporarily effective, but extremely maladaptive, acting out behaviors with new skills and emotion regulation methods. She will continue to need support and remain a risk for suicide, but the risk has diminished significantly. We hope that her suicidality can be overcome completely in time through ongoing therapy and increased relational resources.
References
Linehan, M.M. (1993). Cognitive behavioral treatment of borderline personality disorder. Guilford: New York.
