Volume 6, Issue 2
Suicidality and Eating Disorders
Suicidality and Eating Disorders: Case Analysis
With the current issue of The Remuda Review, we continue our series of articles on common co-occurring problems faced by eating disorder patients. Throughout this series, we are considering the assessment, conceptualization, and treatment of self injurious behavior, anxiety disorders, mood disorders, substance use, trauma, personality disorders, and other co-occurring issues within Remuda’s bio-psycho-social-spiritual model. In each article, we consider how these co-occurring issues relate to eating disorder development, symptoms, and maintenance, and, where relevant, variable manifestations based on age, development, and culture.
The present issue focuses in depth on our seventh topic: suicidality and eating disorders. Patients with eating disorders have the highest suicide risk of all psychiatric disorders, including disorders of established high suicide risk such as major depression, sedative abuse, mixed drug abuse, and bipolar disorder. As such, there is a clear need to understand this co-occurrence and the best, evidence-based methods for addressing it. Toward this end, we hope the article and case study in this issue of The Remuda Review will serve as a short primer on best practices for understanding, assessing, and treating this potentially dangerous co-occurrence.
Suicidality and Eating Disorders
Amy N. Spahr, MSW, LCSW
A. David Wall, PhD
Kevin R. Wandler, MD
Remuda Ranch at The Meadows Programs for Eating Disorders
Every sixteen minutes, an American dies by suicide (McGreevey, 2005). Suicide is the 11th leading cause of death in the US. Among those who commit suicide, half saw a clinician in the weeks prior to their death. In the ten years ending December 2004, 415 reported suicides occurred in healthcare facilities. The majority occurred in psychiatric hospitals and units (McGreevey, 2005), with more suicides likely remaining unreported. During psychiatrists’ and therapists’ careers, there is approximately a 50% chance that one of their patients will commit suicide (Lott, 2000). Each year, in addition to 33,000 completed suicides, a million Americans attempt but do not complete suicide.
Suicide Risk Factors and Causes
A risk factor is a variable associated with an increased risk of a specific disease or event. Risk is determined by comparing those exposed to the factor with those not exposed. When those exposed to the factor are more likely to develop a disease or experience an event compared to those not exposed, that factor is considered a risk factor for the disease or event in question.
Risk factors are not necessarily causal. For example, being young cannot be said to cause measles, but young people are more at risk for measles since they are less likely to have developed immunity. Measles is caused by a particular infectious agent. Youth, and other factors such as suppressed immunity and poor nutrition, merely increase the likelihood that the causal agent, the measles virus, will be capable of triggering the actual illness in particular individuals.
As opposed to risk factors, causes lead directly to a specific disease or event. Their capacity to do so may increase in the presence of certain risk factors and decrease in the presence of protective factors.
Sometimes risk factors can also become causes, so there is room for overlap. For example, someone who is depressed is more likely to commit suicide. Thus, depression is a risk factor for suicide. Depressed people may actually commit suicide for a variety of reasons or causes. Their suicide may be caused by a chronic illness, a major loss, or other event. When such events occur in the lives of those who are depressed, the underlying depression makes them more vulnerable to choosing suicide, even though the depression itself did not cause the suicide. Yet, in some depressed persons, the cause of suicide is the depression itself—hopelessness and despair. There is no other condition or event present. This overlap between risk factors and causes will be evident below as we discuss both categories in relation to suicidality.
A range of risk factors has been identified that increase the likelihood that someone will attempt and/or die by suicide. Quite importantly, psychiatric patients are much more likely to attempt suicide than the general public. Out of the already high risk group of psychiatric patients, those with eating disorders (EDs) have the highest suicide risk.
Table 1, taken from the American Psychiatric Association’s Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors (Jacobs et al., 2003), demonstrates that EDs have the highest Standardized Mortality Ratio (SMR). The SMR is the observed mortality to the expected mortality and approximates the risk of mortality resulting from suicide in the presence of a particular condition. The general US population has an SMR value of 1 with an annual suicide rate of 0.014% and lifetime rate of 0.72%. Any SMR greater than 1 indicates an increase over the annual suicide rate of the general public.
EDs have an SMR of 23.1, higher than all other psychiatric disorders, including other disorders of established high suicide risk such as major depression, sedative abuse, mixed drug abuse, and bipolar disorder.
Having an ED—more specifically anorexia nervosa—is the single most significant psychodiagnostic risk factor for suicide. Patients with bulimia are also at risk for suicide due to the impulsivity commonly associated with bulimia. Furthermore, suicides in ED patients are likely to be underreported. Hence, the suicide risk associated with EDs may be even greater than indicated in Table 1.
When we consider the suicide risk data in Table 1, a critical, unanswered corollary question arises: How great is the suicide risk for a patient who has anorexia nervosa, has attempted suicide before, has a substance abuse diagnosis, major depression, and obsessive-compulsive disorder—each of which is a significant suicide risk factor in itself? This combination of disorders/conditions is frequently seen among ED inpatients. To what extent does the presence of these comorbidities have a synergistic effect on suicidality? We simply do not know.
Clinical experience suggests that the majority of ED patients deny that they are engaging in ED behaviors to die or passively commit suicide. In spite of such denials, due to the high suicide risk associated with EDs, all ED patients clearly need formal assessments for suicidality.
Hall and Platt (1999) reviewed 100 suicide attempts in a major metropolitan area. The best predictors of suicide attempts were the presence of a mood disorder with relentless anxiety; anhedonia; recent conflict or loss; insomnia; and alcohol abuse.
Table 1. Risk of Suicide in Persons with Psychiatric Conditions (please call 1-800-445-1900 for a printed version of this table)
Psychiatric Condition - # Studies - Standardized Mortality Ratio (SMR) - Annual Suicide Rate (%) - Estimated Lifetime Suicide Rate (%)
Those with prior suicide attempts - 9 - 38.40 - 0.549 - 27.5
Eating Disorders - 15 - 23.10 - unavailable - unavailable
Major Depression - 23 - 20.40 - 0.292 - 14.6
Sedative Abuse - 3 - 20.30 - unavailable - unavailable
Mixed Drug Abuse - 4 - 19.20 - 0.275 - 14.7
Bipolar Disorder - 15 - 15.00 - 0.310 - 15.5
Opioid Abuse - 10 - 14.00 - unavailable - unavailable
Dysthymia - 9 - 12.10 - 0.173 - 8.6
Obsessive-Compulsive Disorder - 3 - 11.50 - 0.143 - 8.2
Panic Disorder - 9 - 10.00 - 0.160 - 7.2
Schizophrenia - 38 - 8.45 - 0.121 - 6.0
Personality Disorders - 5 - 7.08 - 0.101 - 5.1
Alcohol Abuse - 35 - 5.86 - 0.084 - 4.2
Pediatric Psychiatric Disorders - 11 - 4.73 - unavailable - unavailable
Cannabis Abuse - 1 - 3.85 - unavailable - unavailable
Neuroses - 8 - 3.72 - unavailable - unavailable
Among those who have been hospitalized specifically for depression, the risk of eventual suicide increases nearly four times. Hopelessness is one of DSM-IV’s diagnostic criteria for depression. “High baseline levels of hopelessness have… been associated with an increased likelihood of suicidal behaviors… [I]nterventions that reduce hopelessness may be able to reduce the potential for suicide” (Jacobs et al., 2003).
Co-occurring anxiety is common in patients with EDs and also increases the risk of suicide attempts and completion. “Evidence suggests anxiety disorders are associated with a six to ten-fold increase in suicide risk” (Jacobs et al., 2003).
Substance abuse, specifically sedative, mixed drug, opioid, alcohol, and cannabis abuse are five of the major risk factors for suicide. In 25-50% of suicides, alcohol abuse or dependence is present. Depression also co-occurs in the majority of those with alcohol abuse/dependence who die by suicide (Jacobs et al., 2003).
Patients with personality disorders have nearly a seven-fold increased suicide risk. About 1/3 to 1/2 of people who die of suicide have a personality disorder, with borderline and antisocial personality disorders the most common. Co-occurring substance abuse and depression are noted in the majority of personality disorder patients who die from suicide. Interestingly, “the patient with borderline personality disorder who is attempting to manipulate the environment (act out or self harm), is at a lesser risk than the patient with borderline personality disorder who presents in a highly regressed, dissociative state” (Gunderson, 1984).
Table 2 reports the percentage of co-occurring psychiatric diagnoses among Remuda’s 6923 ED inpatients admitted between 1/1/1990 and 12/31/2006. The vast majority, 97%, have one or more co-occurring psychiatric diagnoses. Overall, 89% of Remuda’s inpatients have a depression diagnosis. Bipolar disorder has been diagnosed in 4% of Remuda’s inpatients, but in admissions since 2000, bipolar diagnoses have risen to nearly 10%. Depression, bipolar disorder, and ED are among the top five psychiatric diagnoses associated with suicide risk. In addition, 67% of Remuda’s inpatients have a co-occurring anxiety disorder, 22% a substance use disorder, and 35% a personality disorder—each of which aggravates suicide potential. Obviously, given their diagnostic profiles, inpatient ED populations evidence multiple suicide risk factors.
Although ED patients’ multiple psychiatric diagnoses can be listed separately on an assessment report or billing sheet, in the reality of a patient’s daily life, these conditions comingle. The disorders impact each other. For example, depression and anxiety can increase ED symptoms, and ED symptoms can increase depression and anxiety, which can in turn increase substance use behaviors. The multiple diagnoses often interact and exacerbate one another.
In Remuda’s experience, ED inpatients who have attempted suicide before entering treatment have significant depression, anxiety, hopelessness, and sometimes impulsivity. Remuda patients who have depression with anxiety were more likely to act on suicidal ideation than those with depression characterized by psychomotor and cognitive slowing.
Diagnostic categories constitute one type of suicide risk factor, but other factors exist. A comprehensive list of suicide risk factors identified by research appears below (Jacobs et al., 2003).
Previous suicide attempt(s)
History of psychiatric disorders, particularly depression
History of alcohol and/or substance abuse
Family history of suicide
Family history of child maltreatment
Feelings of hopelessness
Impulsive or aggressive tendencies
Barriers to accessing mental health treatment
Loss: relational, social, work, financial
Easy access to lethal methods
Unwillingness to seek help due to stigma of mental health, substance abuse, or suicidal thoughts
Cultural and religious beliefs—for instance, belief that suicide is a noble solution to personal dilemmas
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Patients with prior suicide attempts are at the highest suicide risk, regardless of co-occurring diagnoses. A suicide attempt by any method is associated with a 38-fold increase in later suicide risk. It has been estimated that over a quarter of patients who unsuccessfully attempt suicide will eventually die by suicide at a later time.
Table 2. Co-occurring Psychiatric Diagnoses of Remuda’s Inpatients (please call 1-800-445-1900 for a printed version of this table)
Diagnosis - Children - Adolescents - Adults - Total
ANY PSYCHIATRIC COMORBIDITY - 97% - 96% - 97% - 97%
ANY DEPRESSIVE DISORDER - 78% - 88% - 90% - 89%
Major Depression - 28% - 50% - 56% - 54%
Dysthymia - 8% - 4% - 12% - 10%
Depression Not Otherwise Specified - 57% - 42% - 36% - 38%
Bipolar Disorder - 2% - 4% - 5% - 4%
Attention Deficit/Hyperactivity Disorder - 5% - 7% - 7% - 7%
ANY ANXIETY DISORDER - 87% - 71% - 65% - 67%
Obsessive-Compulsive Disorder - 24% - 21% - 19% - 19%
Generalized Anxiety Disorder - 31% - 20% - 20% - 20%
Social Phobia - 6% - 7% - 5% - 6%
Anxiety Not Otherwise Specified - 65% - 39% - 27% - 31%
Post-Traumatic Stress Disorder - 2% - 12% - 24% - 20%
ANY PERSONALITY DISORDER - 1% - 12% - 44% - 35%
Borderline Personality Disorder - 0% - 4% - 12% - 10%
Substance Abuse/Dependence - 1% - 15% - 25% - 22%
ED’s primary psychosocial causes are known risks for suicide, including dysfunctional family systems, failure to learn how to regulate and express emotions in the family of origin and how to effectively deal with interpersonal conflicts, high social sensitivity, substance use, and impulsivity. These factors both cause ED problems and increase suicide risk. It is important to note, however, that having an ED in itself increases suicide risk regardless of cause, comorbid diagnoses, and conditions.
Research has also identified factors that may protect against suicide. Ohlschlager and Shadoan (2005) summarized these protective factors. They reported that being a religious believer is protective over being a non-believer; being married is more protective than being single, divorced or widowed; heterosexuals have a lower risk than homosexuals; females have a lower risk than males, in that 70% of completed suicides occur among males, even though women attempt suicide at least twice as often as males.
Although we understand risk factors that make people vulnerable to suicide, when we hear about someone who has committed suicide our first question is almost invariably, “why?” We often never know fully why, although we may be able to ascertain some of the causes. Reasons for suicide may build up over years—long-term causes; or may be due to a dramatic change for the worse—short-term causes.
Chronic illness, mental or physical; e.g., unrelenting depression.
History of behaviors over many years that are seen as shameful, e.g., job failures, addictions.
History of being abused, especially if it is ongoing with little hope for change.
History of chronic social rejection; a physical or behavioral characteristic that causes someone to be ridiculed or ostracized.
Trauma that continues to haunt the person over many years.
Rejection by family, especially early in life.
Diagnosis of deteriorating, irreversible, and/or terminal disease; e.g., slowly going blind.
Diagnosis of terminal illness in, or death of, a loved one; risk is highest on the anniversary date of the death.
Public shame and humiliation, e.g., fired from a job.
Losses in general: e.g., job, standard of living, divorce or other separation, social status, savings.
Relapse into addiction.
Entire hope for the future placed in something/someone that suddenly ends, e.g., a relationship or job.
Long- and short-term causes can co-occur to prompt a suicide. A short-term cause may sometimes seem relatively unimportant, but can be the straw that breaks the camel’s back. For example, an individual may have experienced a long history of social rejection combined with one of his/her few friends suddenly moving away. The latter event may seem relatively trivial, but against the backdrop of long-term social isolation, it may be enough to precipitate a suicide.
Suicide among ED patients is often caused by the same short- and long-term factors that lead to suicide in non-ED patients, including lost relationships, chronic depression, and the hopelessness that is common among people who are unhappy with their lives and see no change in sight. Many ED patients live in constant shame about their ED. They are trapped in a disorder that they have tried to stop repeatedly. Many no longer experience positive gains from the ED; it compels them and controls their thoughts and feelings. Each failure intensifies shame, self-loathing, and hopelessness.
Such patients may proclaim that “either the ED stops, or I am going to kill myself.” We have heard this statement many times from our ED patients. For everyone who verbalizes such a proclamation, there may be more who feel this way but keep it to themselves. The popular conception that EDs are about vanity often misses the mark. At some point the ED becomes more like an intolerable curse. Suicide may appear the only way out. This is especially true, because ED patients have relied upon their ED to hold back pain and provide a sense of control. When the ED becomes as painful as the wounds it once safeguarded against, and the control the ED has over the individual overcomes the sense of control that it once provided, all may seem lost.
ED patients often have obsessions that are intrusive, constant, and highly distressing; e.g., “You will get fat if you eat that,” or “You are an ugly fat pig.” Eating intensifies these obsessions. The outside world of family, friends, and therapist typically pressure the patient to eat, but the patient knows if she does she will have to endure the intense fear and distress of these obsessions. She is in a double bind. Everyday she must face intense anxiety, encountering her worst fears with no break. It is difficult to handle this constant, frenetic battle in her thoughts and emotions and she may see know way out but suicide.
Similarly, many girls and women say that they would rather die than gain weight. For some this is not an empty statement. Weight gain may increase suicide risk. As patients are forced to gain weight, they may feel overwhelming guilt if they eat because they have violated their strict rules. They also feel guilt if they do not eat because they have let their families down. When does this tug-of-war end?
The good news is that these problems are treatable. Catching the disorder before it escalates to this degree and responding with an appropriate level of treatment is imperative. We explore this below.
Due to the high suicide potential of Remuda’s patients, Remuda is proactive in assessing and screening for suicidality. Our risk assessment begins before patients are approved for admission. We ask a series of questions during our intake process to identify someone who may be a suicide risk. Naturally, these questions include a screening for all psychiatric disorders, current treatment for psychiatric disorders, a history of suicide and parasuicide attempts/gestures, and history of all hospitalizations and treatments for depression, anxiety, post traumatic stress disorder, and substance abuse. We ask if patients have ever had thoughts of death or killing themselves, and if they are currently thinking of killing themselves. If the latter, we ask about thoughts on how, when, where, means, and whether a close friend or family member has ever committed suicide. For patients who are actively suicidal and live out of town, we recommend immediate local psychiatric support.
On the basis of patients’ answers to this pre-admission suicide screen, patients are placed at various levels of observation when they admit to Remuda. In particular, anyone who has attempted suicide in the past year, has current suicidal ideation, or has been hospitalized in the past 30 days for suicidality is placed on Suicide Observation Status (SOS). Of patients needing SOS, 2/3 are identified pre-admission. Once full in-house assessments occur, patients not identified during pre-admission screening but who have significant active suicidal ideation with self-harm are also placed on SOS.
SOS is an awareness and safety protocol. Patients on SOS are able to fully participate in Remuda’s treatment program when they are not suicidal. They are more closely monitored than others. Their luggage and clothing is even more carefully searched; appropriate family members are given education about the SOS protocol, informing them that it is imperative for us to search all items brought back from off-grounds passes. SOS patients complete weekly self-assessment questions regarding suicidal ideation and behaviors. A systematic assessment of SOS patients occurs at discharge, including a documentation and communication process that allows for enhanced dialogue between inpatient and outpatient treatment teams. A comprehensive suicide prevention process also embellishes standard aftercare planning.
Kanapaux (2004) reports there are no suicide scales, extant or in development, that can be employed over the phone and are specific or sensitive enough for general clinical use. He recommends that suicide assessment be left to the judgment of the provider based on a comprehensive assessment. Remuda uses psychological tests such as the Minnesota Multiphasic Personality Inventory-2 and Beck Depression Inventory-2 to screen for suicide. These tests can be helpful and may be the first clue that a patient is suicidal, as some patients are willing to admit to suicidal issues on tests but not during face-to-face interviews. Of course, these tests cannot replace clinical interviews and, when possible, collateral histories.
There is no specific psychopharmacologic treatment for suicidality per se in ED patients. Instead, we treat the contributing co-occurring issues. Patients with depression or anxiety may be given an antidepressant, anxiolytic, or antipsychotic medication. For more details on psychiatric medication with EDs, see Wandler (2007).
In 2004 the US Food and Drug Administration (FDA) issued a black box warning on the use of all antidepressants in children and adolescents. These medications may, in certain cases, increase suicidality. Later revisions to the FDA black box warning indicate the apparent beneficial effect of antidepressants in older adults and remind health care professionals that depressive disorders themselves are the most important cause of suicidality, not the medications. For the actual FDA statement, see www.fda.gov.
All patients should be closely monitored when any medications are prescribed. We prescribe medications such as antidepressants only when a patient’s licensed and trained medical or psychiatric provider believes that such medication is needed. Each individual patient is evaluated prior to medication being considered. We exercise caution when we prescribe medications. In addition, we have the benefit of closely observing and monitoring patients taking all prescribed medications in a controlled environment for at least two months while in treatment. This observation period is one of several rationales for hospitalizing ED patients who have co-occurring depression or anxiety.
Professional responses to suicidal behavior or threats differ depending on the patient, past and present situations, and the therapeutic relationship. Considerations for professionals to review when treating suicidal patients include:
Be aware of your own feelings and beliefs regarding death and suicide.
Every patient should be thoroughly assessed for suicide and self injury behaviors.
If you have a patient who has a past history of suicide, continue to reassess for safety and suicide risk throughout treatment.
Be aware of the patient's specific, past, suicide-precipitating events and factors.
Develop a treatment plan to target suicidal behaviors and to provide education to the patient and family.
Involve the family and the patient's support system in the management and treatment of suicidal risk.
Recognize the role of addictions, comorbidities, and other psychosocial issues in suicide.
Develop a crisis response protocol to address active suicidal plans and/or behaviors.
If a patient is dangerous to self or others and will not consent to interventions intended to reduce those risks, professionals may be justified in breaking confidentiality to the extent needed to address the safety of the patient and others. Know your local laws and professional ethical codes.
Determine if suicidal behaviors are primarily impulsive and automatic or deliberate and planned.
Document essential information regarding suicide risk assessment, interventions, and progress.
Team collaboration and coordination of care is critical. Establish clear role definitions, regular communication among team members, and advance planning for management of crises.
Assess the environment for means to reduce self-injury. Work with the patient and family to assist with environmental interventions.
Remember that suicide contracts may falsely lower clinical vigilance without altering patient suicidality.
Give the patient and family resources for crises: e.g., telephone numbers of on-call therapists, suicide hotlines, and hospitals.
Cognitive-behavioral therapy reduces the rate of repeated suicide attempts by 50% during a year of follow-up. A previous suicide attempt is among the strongest predictors of subsequent suicide, and cognitive-behavioral therapy helps individuals who struggle with suicidal ideation to consider alternative actions when suicidal thoughts arise (Brown, Ten Have, Henriques, Xie, Hollander, & Beck, 2005). Dialectical Behavior Therapy (DBT) reduces suicide attempts by half compared with other types of psychotherapy available in the community in patients with borderline personality disorder (Linehan et al., 2006). DBT also reduces the use of emergency room and inpatient services. DBT requires structured protocols for responding to suicidal behaviors, parasuicide, threats, and ideation. DBT is a treatment strategy that emphasizes the importance of balancing change and acceptance. It is very specific in the treatment targets and focuses therapy on 1) reducing life-threatening suicidal behaviors; 2) reducing therapy-interfering behaviors; 3) reducing behaviors that have a severe effect on life quality; and 4) increasing general coping skills. Standard DBT uses group skills training, individual therapy, on-call coaching, and team consultations (Linehan, 1993).
ED Adolescents and Suicide
Suicidal adolescents present special challenges. Although teen suicide rates are actually lower than most adult rates, there is still significant suicide risk. Suicide is the third leading cause of death in teens behind accidents and homicides. Having a gun in the home is associated with a dramatic increase in the risk of successful teen suicide.
The presence of “copycat” suicides in teens speaks to teenagers’ tendency to over-identify with peers. Severely depressed and/or alienated teens tend to form strong, sometimes vicarious, bonds with other teens perceived to be suffering the same fate. Adolescents with EDs may strongly bond and identify with other ED teens. If one teen commits suicide, suicide risk increases for their affiliation group.
Girls with EDs often have intense conflicts with their parents over the ED, in addition to normal parent/teen conflicts such as dating and peer groups. Threats and acts of suicide can be intended to gain a measure of control over parents, especially when communication is non-existent or has broken down. In other cases, guilt and feelings of failing the family lead to suicidal acts. In addition, many of the issues discussed above relative to adult suicidality similarly impact teens.
Because teens tend to be more impulsive, feel emotions with greater intensity, and do not possess the experience to understand that situations can change in the future, they can be highly susceptible to suicidal impulses. This is especially true after major arguments, changes in family structure such as divorce, or the imposition of strict boundaries such as prohibition on dating. ED patients can become suicidal after parents insist that they accept treatment for their ED. Typically, this leads to threats and gestures without intent to actually die, but teens often do not understand which gestures may be lethal. As such, any indication of suicidality in ED adolescents must be taken seriously. At the same time, threats of suicide cannot be reinforced by parents giving into the demands of the teen. To navigate this complex terrain, immediate professional help is recommended.
Therapeutic Responding Following Completed Suicides
The suicide of a patient can have a significant professional and personal impact on clinicians. The emotional responses can include denial, shame, anger, guilt, fear, and sadness. There may be reactions of self-doubt or self-blame. Given the complexity of emotions and responses, it is important that clinicians receive support from their colleagues. The American Psychiatric Association (Jacobs et al., 2003) offers three guidelines to assist in the management of suicide in one's practice. First, if a patient dies by suicide, ensure that his or her records are complete. Second, conversations with family members can be appropriate, allay grief, and assist devastated family members in obtaining help. Third, in speaking with survivors, care must be exercised not to reveal confidential information about the patient and not to make self-incriminating or self-exonerating statements.
We have worked with patients who, in times of severe pain and desperation, grossly underestimate the impact their suicide would have on their family and friends. Patients may say: “They would be better off,” or “They will get over it.” These are rationalizations to make the act more tolerable to the one contemplating it. To be sure, we have never met a family member of a suicide who would agree with any of these statements. The wounds created by suicide in the family can be extraordinarily deep and lasting. Suicide often engenders profound depression and guilt in the surviving family.
Families are often ashamed that a loved one committed suicide. As such, it is important to state openly that the act of suicide does not undo the good that was in the larger scope of the person’s life. Suicide should not bring shame to either the person who attempts or commits suicide, or surviving loved ones. There is never a good reason or excuse to speak ill of or judge a suicidal person or their survivors. We are called by God “to bind up the brokenhearted,” not to wound them more deeply.
Suicide does not mean that a person was defective, sinful, or weak. Many who would never even think of suicide in their current circumstances may have chosen this same path had they found themselves in the circumstances that the suicidal person endured. In short, it is possible for us to be proud of and speak highly of someone who has committed suicide. We can recall the good moments and wonderful times.
Those who experience the suicide of a loved one should seek counseling and, if possible, join a support group of others who have traveled this painful road. Through these methods, accompanied by prayer and other spiritual practices and God’s healing grace, survivors can hope to heal the wounds left by the suicide, forgiving themselves and the person who chose to end their life so abruptly.
In the Bible, suicide often occurs in once godly people who have turned away from God. These Bible stories, taken together, can be interpreted to suggest that suicide may be the result of rebellion against God and evil practices. The most infamous suicide in the Bible is Judas Iscariot, who committed suicide following his betrayal of Jesus Christ. Because of this story, the name of Judas has become a synonym for treachery and betrayal. His suicide is an image burned into billions of minds, portrayed repeatedly in religious and secular literature and art.
Another Biblical example of suicide is King Saul. In 1 Samuel 16 we read that, due to a long history of sinful behaviors, Saul lost favor with God. A downward spiral culminated with his suicide. “…Saul took his own sword and fell on it.”
It would violate commonly accepted Biblical interpretative methods (Corley, Lemke, & Lovejoy, 2002; Zuck & Campbell, 2002) to derive a theology of suicide purely from examples, such as those of Saul and Judas. These were tragic stories ending in suicide. They tell us about the individuals’ experiences, but do not tell us about God’s heart on the matter of suicide. From experience, we know that suicide may strike those who have lived innocent and godly lives as well as those whose errant deeds have led to tragic ends. We must therefore examine a larger Biblical picture.
The Bible records stories of faithful and godly people who became so overwhelmed that they longed for death. The great prophet Elijah “…prayed that he might die. ‘I have had enough, Lord,’ he said. ‘Take my life…’” (1 Kings 19:4). The Apostle Paul wrote, “We were under great pressure, far beyond our ability to endure, so that we despaired even of life” (2 Corinthians 1:8). As such, contemplating death and possibly suicide during times of great despair would not appear to be inconsistent with an otherwise godly life. Healthy people may reach this point. Research suggests, for example, that 20% of Americans have contemplated suicide at one time or another during their lives (Kessler, Borges, & Walters, 1999).
This apparent Biblical neutrality on suicide is used by some to support an individual’s right to commit suicide. Supporters of this position point further to such stories as Samson’s (Judges 16), who killed himself in revenge against the Philistines. Indeed, God enabled Samson to carry out this act by restoring his strength. Suicide advocates also argue that the Bible does not openly state that suicide is wrong.
Yet most Christians believe that the sanctity of human life and the sovereignty of God over human life are concepts embedded throughout the Old and New Testaments. Much has been written in support of this view. O’Mathúna (1998) provides an in-depth response to pro-suicide arguments, offering solid evidence that suicide is not condoned by the Bible’s apparent silence in certain narratives or lack of specific prohibition against suicide.
Moreland (1998) suggests that we take into account the person’s intentions and motivation for suicide. Consider the following examples: a solider who falls on a hand grenade to save his friends; a mother who kills herself to donate an organ to her dying daughter; a parent who has just lost a child to murder; a patient with a few months to live dealing with excruciating pain; a spouse who was abandoned by a partner of 30-years; and a teen whose boyfriend left her for another girl. In reading these, we naturally think about the reasons the person likely had for the suicide. Many people would fully understand and even honor the soldier’s act. Many would not even consider his act to be suicidal. On the other hand, although most people would have some sympathy for the jilted teenager, most would likely not see this as a legitimate reason for suicide. Between these two extremes, people would likely have differing viewpoints about the suicide’s legitimacy. “In the final analysis one’s approach to suicide is determined largely by the worldview one brings to the issue” (Moreland, 1998, p. 196).
Perhaps the most common secular foundation of morality in our culture is a combination of two principles: 1) individual autonomy, and 2) no harm to others. From this perspective, suicide could be construed as moral. Christians agree with the concept of individual liberty balanced by regard for others, but add the question, what does God want? Christians believe the answer to this question comes largely from the Bible, and that the Bible indicates that suicide is not God’s will. If one defines sin as doing something outside of God’s will, then suicide is a sin. God does not want people to commit suicide; God is the one who decides when each of us will breathe our last breath (Matthew 6:27).
Some Christian teachers have deemed suicide an unforgivable sin, because in Christian belief the dead cannot repent and receive forgiveness. If this argument were true, however, any person who died suddenly and without warning might share the same condemnation if s/he had recently committed a sin and had not yet repented of it. By analogy, one can infer that suicide may be forgivable and would not necessarily cause someone to “lose his/her salvation”. Even in Christian traditions that distinguish among gradations of sin, suicide would result in condemnation only if it were committed with full, rational knowledge of its gravity, implications, and consequences—a situation unlikely to apply to the large majority of people who commit suicide because they are in the throes of extreme emotional distress and mental confusion. Even then, Scripture assures us that God is exceedingly merciful and understands fully the frailty of our humanity. “For we do not have a high priest who is unable to sympathize with our weaknesses, but we have one who has been tempted in every way, just as we are…” (Hebrews 4:15). As such, we are on solid Biblical ground in concluding that suicide can be forgivable, covered by God’s plan of redemption.
According to Scripture, we are all born with sinful natures set in rebellion against God (Romans 7), making choices to maximize pleasure and avoid pain, even choices that harm others or ourselves. This is not new information! God designed his redemption plan to address this very situation. As Christians, we believe that suicidality, even completed suicides, are accounted for in God's loving redemption plan. "For God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life… God did not send his Son into the world to condemn the world, but to save the world... Whoever believes in him is not condemned…” (John 3:16-18).
So, why do Christians—who have known the love and grace of God, understand the “blessed hope”, believe that we are more than conquerors (Romans 8:37), and have faith that “all things work together for the good of those who love God” (Romans 8:28)—kill themselves? The answer has been offered repeatedly in the foregoing issues of this journal: Christians are not immune to biological, psychological, social, and spiritual problems. A person may endure tremendous pain for months or years, yet suicide can occur with just one moment of human weakness.
When Christians contemplate this situation, it is easy to fall into a false dichotomy–either the person struggling with suicide is unfaithful and ignoring God’s deliverance, or God is not being faithful to the person. This dichotomy dramatically surfaces in the Book of Job, which labors over the question, did Job’s tragedies arise from his sin or had God abandoned him? As Christians, we believe that God is faithful, although at times we may feel that He has abandoned us. It is also wrong to rush to judgment of the suicidal person. Theologies that proclaim the Christian life to be carefree, blessed with abundant physical health, and void of conflicts and heartache, intensify this dilemma and add shame to those who struggle. Jesus clearly said, “In this world you will have trouble…” (John 16:33). Suffering is not shared equally across humanity; some suffer more than others. Suffering can be caused by sinful disobedience, but good people may suffer more than those whose lives are filled with immorality.
Furthermore, sanctification is not an instantaneous event, but a process. Spiritually, Christians are “new creations” and can look forward to eternal life. But conversion does not immediately change their personality styles or ways of coping with emotional pain, or provide them with instant skills to form healthy and intimate relationships. These issues may change over time through the process of sanctification. Hence, Christians cannot forget that people are often acting out of deep emotional pain. We should work to prevent suicide, doing all we can to alleviate the physical and emotional suffering that leads to suicidal behavior. We do not need to reinforce, excuse, or condone ineffective behaviors, but to listen to those who exhibit them with our hearts, speaking the truth in love. Helping these individuals can be a challenge. Communication of love and acceptance combined with gentle boundaries is usually the best approach. If persons become acutely suicidal, calling their therapist, community mental health agency, crisis hotline, or the police is not an act of betrayal, but an act of love that eventually teaches them that you take their threats seriously and want them to live. For more information about how to approach someone who is in deep pain and possibly suicidal, see Demy and Stewart (1998). Finally, if and when a person succumbs to suicide, we are not to judge, but “mourn with those who mourn” (Romans 12:15).
Suicidal persons with a genuine intent to die for reasons other than the impact it will have on the people in their lives, have two primary beliefs: 1) death is not as bad as whatever they are going through, and 2) their situation is very unlikely to change. People in crisis have poor judgment, clouding their assessment of their current circumstances and their ability to predict whether their situation will change. A broken-hearted spouse may cry, “I cannot live without her.” The intensity of the emotion overpowers reason and judgment and the emotion becomes the basis of the person’s reality. Down the line this person is likely to have a very different viewpoint, but in the midst of the crisis, emotional reasoning prevails.
Faith in God is a significant protective factor against suicide. There may be many reasons for this, including hope that a loving God will see the person through their pain and belief that God does not want us to commit suicide. Christians who commit suicide must overcome the protective factors associated with faith. To do this, Christians may tell themselves: God will forgive me. God knows how much I am suffering. God doesn’t care about me anymore. The Bible doesn’t say that suicide is wrong. I don’t care what God thinks anymore. Suicide is just another example of my failure to be a good Christian. I will take my chances on heaven and hell, because it couldn’t be any worse than my life here. I am no good to my family; God will provide for them. The sad truth is that Christians do sometimes find reasons to suicide. We do not know how many times the person resisted the temptation; we only know that on one occasion they were unable to resist.
Dangers for us, as Christians, are burying our heads in the sand about the issue of suicide in the Christian community, or brushing it aside by blaming it on the suicidal person’s lack of faith or sinfulness. Churches would do well to openly discuss suicide, educate congregations, allow people to acknowledge struggles without fear of judgment, and compassionately support families and friends of those who have committed suicide without reducing their loved one’s life to a single act. Churches can be places of healing and support to the survivors of suicide, no different than if their loved one had died of natural causes.
Brown, G.K.,Ten Have, T., Henriques, G.R., Xie, S.X., Hollander, J.E., & Beck, A.T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294, 563-70.
Corley, B., Lemke, S., & Lovejoy, G. (Eds.). (2002). Biblical hermeneutics: A comprehensive introduction, interpreting Scripture, 2nd Edition. Nashville, TN: B & H.
Demy, T.J. & Stewart, G.P. (Eds.) (1998). Suicide: A Christian response, crucial considerations for choosing life. Grand Rapids, MI: Kregel.
Gunderson, J.G. (1984). Borderline personality disorder. Washington, DC: American Psychiatric Press.
Hall, R.C.W. & Platt, D.E. (1999). Suicide risk assessment: A review of risk factors for suicide in 100 patients who made severe suicide atttempts: Evaluation of suicide risk in a time of managed care. Psychosomatics, 40, 18-27.
Jacobs, D.G., Baldessarini, R.J., Conwell, Y., Fawcett, J.A., Horton, L., Meltzer, H., Pfeffer, C.R., & Simon, R.I. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry. Retrieved April 27, 2007, from www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf
Kanapaux, W. (2004). Guideline to aid treatment of suicidal behavior. Psychiatric Times, 21, 8.
Kessler, R.C., Borges, G., & Walters, E.E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Study. Archives of General Psychiatry, 56, 617-626.
Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.
Linehan, M.M., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757-66.
Lott, D. (2000). Risk management with the suicidal patient. Psychiatric times, 17. Retrieved April 24, 2007 from www.psychiatrictimes.com/ p000809.html.
McGreevey, M. (2005). Reducing the risk of suicide. Oakbrook Terrace, IL: Joint Commission Resources.
Moreland, D.P. (1998). The morality of suicide: Issues and options. In T.J. Demy & G.P. Stewart (Eds.). Suicide: A Christian response, crucial considerations for choosing life. Grand Rapids, MI: Kregel.
O’Mathúna, D.P. (1998). But the Bible doesn’t say they were wrong to commit suicide, does it? In T.J. Demy & G.P. Stewart (Eds.). Suicide: A Christian response, crucial considerations for choosing life. Grand Rapids, MI: Kregel.
Ohlschlager, G. & Shadoan, M. (2005). Suicide: Assessment & intervention in the ultimate crisis. Christian Counseling Today, 13, 22-33.
Wandler, K.R. (2007). Psychopharmacology in patients with eating disorders. In E.J. Cumella, M.C. Eberly, & A.D. Wall. Eating disorders: A handbook of Christian treatment. Nashville, TN: ACW Press.
Zuck, R.B. & Campbell, D. (2002). Basic Bible interpretation. Nashville, TN: Victor.
Suicidality and Eating Disorders: Case Analysis
Sherrie Maher, PhD
Remuda Ranch at The Meadows 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.
Linehan, M.M. (1993). Cognitive behavioral treatment of borderline personality disorder. Guilford: New York.
Next Issue: Body Dysmorphic Disorder and Eating Disorders
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