Do’s and Don’ts for Talking to Children about Body Weight

By Jessica Setnick, MS, RD, CEDRD

Negative comments and criticism about body sizes, shapes and weights are not harmless. They can and do lead toward unhealthy eating and exercise behaviors that in a susceptible child or teen can begin the path toward an eating disorder.

Although not all eating or weight issues can be prevented, some triggers and harmful beliefs can be avoided.

Ultimately the greatest gift adults can give children with regard to eating is a healthy relationship with food and with their own bodies. Even children who aren’t prone to develop an eating disorder can benefit from an accepting environment. We all have a part to play in creating that environment and in countering negative messages from other sources.

Guidelines for Talking to Kids About Weight and Body Image

Concerned adults can use the following guidelines when communicating with children and teens to convey healthy, realistic ideas about weight and body image.

• DON’T comment on the weight, size, shape or eating of others.
• DO demonstrate through your actions an acceptance of a variety of weights, shapes and eating styles.
• DON’T make judgmental comments (even ones you consider positive or supportive) to children about their weight or size.
• DO simply demonstrate unconditional positive regard and acceptance.
• DON’T give dieting advice to children.
• DO encourage attention to internal hunger and fullness cues, as well as attention and acceptance of a wide variety of emotions.
• DON’T talk about your own weight issues in front of children. EVER.
• DO address your own eating issues with a professional in order to set a good example.
• DON’T weigh children in a public setting.
• DO teach that weight is one of many vital signs that are monitored throughout life; it doesn’t determine your health.
• DON’T equate thinness with happiness or weight loss with confidence.
• DO convey that your weight and what you eat do not make you good or bad and that happiness and confidence are unrelated to body size.
• DON’T ignore weight loss. It is never normal for a child or teen to lose weight, even if that child was overweight at first. Overweight teens are at the HIGHEST risk for developing an eating disorder.
• DO reach out for support and seek professional help for a child or teen who is losing weight.

From a Pea to a Pumpkin: A Prenatal Psychotherapy Group for Women with Eating Disorders

By Angela R. Wurtzel, MA, MFT, CEDS

During the past year three of my long term clients became pregnant. One expressed a strong interest in being a part of a psychotherapy group with other pregnant women to talk about their emotional and psychological lives during pregnancy and preparing to become mothers and parents with their partners. So, I set out to create From a Pea to a Pumpkin: A prenatal psychotherapy group for women with eating disorders and within a few weeks, my first group was formed. This article will highlight and incorporate these women, their experiences in the group and how we have continued as a group postpartum. All of my clients’ identities have been protected in the following article.

The main purpose of the group is to address the conscious and unconscious expectations of pregnancy and motherhood paying particular attention to the dynamics at play for women with or who have struggled with eating disorders. The eating disorder component of the group focuses on the eating disorder of the patient and how it developed in relationship to her early attachment and how this may have an impact on her attachment process with her infant. Most importantly, the group’s underlying frame is to provide a therapeutic holding environment for the women to become and be able to talk openly about their pregnancy experience and how the process of putting thoughts and feelings into words allows for greater insight and potential change.

The prenatal conscious scenario: beginning to speak of the pregnancy experience.

Each woman has a story of how she became pregnant and I believe that the outset of the pregnancy is very impactful on the pregnancy and birth of the child. Containing and articulating this experience into words for women with eating disorders is very important because often the eating disordered woman, even with years of treatment, may have limited self reflection and as a result may reenact their own childhood experiences to express their feelings. For instance, Janice initially became pregnant by secretly going off her birth control and not telling her husband. In the group, Janice was able to voice her wishes of becoming pregnant and she how she always wanted “a kid” and knew that when she married her husband he did not want children. Janice said she couldn’t take no for an answer, and secretly stopped taking her birth control and is now pregnant. Janice clearly explained that she felt justified in wanting what she wanted. The group members and I validated her feelings and added that acting on these feelings was much different from feeling her wanting and subsequent frustration. Through the group process, Janice decided to talk with her husband and together decide what to do about her secret pregnancy. Janice had been seeing me individually for more than two years for binge eating disorder. At the root of her eating disorder is a hunger that is all consumptive; she is determined to acquire what she wants with a strong dissociative quality that allows her to avoid realistic consequences and outcomes of her behavior, urges and fantasies. She came by her all consumptive nature honestly as she was nicknamed in her family the “garbage disposal” because she was encouraged and teased about eating all the leftovers. Janice grew up in a home with no boundaries, no limits and very little protection. At the same time, Janice reports a childhood and adolescence marked with loneliness, fantasy and daydreaming. Devoid of true emotional attunement from her parents and a tremendous amount of verbal abuse from her three sisters, Janice took to taking care of herself into her own hands and found refuge and soothing by over feeding herself. When she decided to become pregnant without her husband’s knowledge it was a reenactment of her childhood experience of being in charge, the one to take care of herself even if someone else’s life might be greatly affected by her own self gratification. When she did tell her husband that she was pregnant he was angry. Her greatest concern was that he would want her to abort the baby. However, he conceded and they went ahead with the pregnancy. At 8 weeks into her pregnancy, Janice miscarried. She was devastated and suffered from a severe grief reaction. This traumatic event unleashed a well of emotion in Janice. We used this experience and time to explore some of her underlying tendencies related to want, frustration and boundaries. She was very concerned that her husband would not be willing to impregnate her again and she began talking about her urges to trick him and stop her birth control. While this was happening inside Janice, she and her husband were also talking directly with each other about the possibility of getting pregnant. Janice was like a little child asking her parent/husband if she could do something, waiting for him to give her the only answer she wanted. She would not take no for an answer and was terribly frustrated. She felt like she was coming out of her skin and actively binged to manage her feelings of frustration and anger. She expressed her anger at me, too, because I held the line with her in her mind, and the group also provided a real frame of reference for her. Janice became pregnant and was happy and relieved. However, she expressed in the group her fear about having another miscarriage.

Janice was binge eating to help regulate her emotions and express that which she had yet to find words for. She maintained a primitive process of using her body as the stage for her emotional expression. Even though she was pregnant and becoming full she felt an urge to take extra care of herself and her unborn baby. Out of fear, she tried to contain her behaviors and talk more openly about her feeding processes. Loss is a very big trigger for eating disorder symptoms, be they real, perceived or anticipated losses. For Janice, her eating disorder failed as a true transitional object during this time of loss because it instead bound her to her excessively gratifying internalized mother. Janice is so ashamed of how she feeds herself. This is a very tender area for her to talk openly about and she usually can only find very concrete words to describe her feeding style. Understanding her urges driving her pregnancy became an important reality for Janice, her child and her family.

The prenatal unconscious scenario: Beginning to speak of the unacceptable pregnancy experience

The unconscious hunger that operates in most women with eating disorders develops from an emotional deprivation during their own infancy. Eating disorders are a means later in life to get rid of the mother and to maintain a tie to her at the same time. Through the process of group therapy, it is possible to uncover these unconscious motivations that can lead to insight and change over time. The intention of providing this type of therapy to prenatal women is to help them become aware of their unconscious hunger in relationship to feeding and attachment. By beginning with the hunger for a pregnancy and then a baby, the story begins to tell itself. By no means should these underlying hungers negate the wish for the pregnancy or a baby, but rather to shed light on what else may be going on with each woman in the group during their pregnancies.

Janice clearly had unconscious hunger and fantasies in becoming pregnant and having a baby. She wanted what she wanted and was driven by an insatiable hunger in which she had even been willing to overstep the rights and wishes of her husband and their vows to consume what she wished for. Her dissociative capacities allowed for this and her unconscious need to fill herself would surpass any ethic or value she may consciously uphold. Because she was so mistreated as a child Janice had very little value of herself. To some extent, Janice and her mother still share the same mind for two. Janice brought herself to therapy to address her eating disorder and to explicitly separate from the destructive effects of her mother. She felt she had lived for her mother’s needs and she could not breathe her own air. She said she knew she would continue to binge eat if she didn’t come to therapy. During the group, Janice had the opportunity to explore and reveal her wishes to have a baby for her self. She wanted someone to love and who would definitely love her. She never pictured an infant, just a friend who she could play with. When she found out she was having a boy, she started thinking about the future, when he would get a girlfriend and leave her. She felt angry and jealous thinking of him leaving her. Her hunger to maintain a narcissistic fusion with her child has been at work and fueling her bond with him before she even conceived him. Her pregnancy fantasies revolved around her own introjected narcissistic demands of her mother.

Another tenet of the group is to help each participant gain insight and sensitivity about her own mother’s early attachment and how it may affect her own internalized expectations of pregnancy and motherhood. At the core of most eating disorder behaviors is a narcissistic fusion with one’s primary caregiver in which the then patient/now mother to be has very little sense of self and the development of the eating disorder becomes her means of separation and individuation. This dysregulated yet persevering attempt at survival will undoubtedly color her interpersonal relationships and her unconscious motivations and attachment tendencies with her own child. Providing a platform for discussing and exploring the attachment tendencies with pregnant women who have eating disorders is essential and therapeutic in helping them develop more attuned and empathic attachment styles. Beginning this process during pregnancy can help the patient bring dissociated thoughts to their conscious awareness with an opportunity to consider other ways to think about how to be with their baby when the baby is born.

Terri had a very intrusive mother. Terri had to sleep in her mother’s bed, spooning her, until her teenage years. She became her mother’s lover and receptacle. Terri remembers as a child repeatedly urinating in her bedroom and spreading her feces on her walls. When she talked about these memories in-group it was clear how severely neglected and used Terri had been by her mother and totally unprotected by her father, who divorced her mother and abandoned Terri. Her brother and sister also abused Terri. There are countless letters and exchanges between Terri and her family of origin that define a narcissistic fusion. Over the years of therapy, Terri weaned herself from her family, physically, emotionally and financially. However, she still maintains a strong wish for a good, decent family to share her life with. During her moments of aloneness in her pregnancy, Terri talked in-group about feeling urges of desire to fuse again with her family and for her daughter to have relatives. She feels jealous and angry that her baby will only have relatives on her father’s side. She wants to give her daughter relatives even if they are bad ones. Terri still continues to struggle with having her own mind and own body. When she impulsively decided to tell her family that she was pregnant, the response from her mother was classically narcissistic. In an email subject: I am going to be a grandmother and this is the best day of my life! Yet, there was no acknowledgment of Terri, how she is doing, who the father is, etc. At first read, Terri felt relieved and satisfied because she pleased her mother and received praise for making her mother happy. During the group she explored her father’s response as well, which was to send her all the quarters he had saved in a jar, she could have those to help with her baby. Terri accepted the quarters and then realized that he consistently sent her “ leftovers and second hand type gifts, not ones that were really chosen for me.” Terri realized, too, that earlier in our group sessions when she had talked about hogging and hoarding her baby that this was how her mother had been with her and that she was reenacting this unconsciously with her own baby. 

The Holding Environment: Attune to each participants potentiality of depressed and anxious mood and body dissatisfaction and provide a framework for therapeutic intervention.

When we ask what the body is, attachment theory can help us understand how internalized attachments can find a voice in the body. Attachment theory can help us to understand how unspoken narratives can take the form of psychosomatic processes or illnesses. This is especially true for people who react to psychological stress through somatic manifestations and pregnancy can affect this process. As these mothers begin to think about their attachment to their baby they have only to call upon their own blueprint of attachment with their mothers and primary caregivers. As we have already explored, one’s own attachment process becomes deeply internalized and is a major factor in the development of eating disorders. Overall, most of the members of this group reported very little body dissatisfaction during pregnancy and some depression of mood and definitely anxiety. Postpartum has been more concerned with body dissatisfaction and the dissatisfaction with the therapist mother who has become the shared skin for each member. I can’t help but think that during the early months after the birth of their babies when the eating and feeding disturbances with each of these women’s babies becomes more possible, the group has been more focused and concerned with their own feeding and body images. It is true that that the only sense of power these babies have in a world that they are entirely dependent on their mothers is in the arena of eating and elimination. Mothers attempt to breast-feed during group and they each coo their baby to feed when sometimes the baby doesn’t seem hungry. Often the mother thinks the baby should be fed and should eat. Sylvia’s baby falls asleep. Terri’s’ baby doesn’t like her right breast, and Alisa’s baby is just a little bit underdeveloped still to get all of the milk from her mother’s breast. It is the battle to get a child to eat that is being reenacted here, and, in the process, these babies may internalize the experience of their bodies being their mother’s for her control, not unlike what was certainly true for each of these mothers. Providing a frame for the mothers in this group to put words to what is happening in these group experiences will prove to be helpful.

Sylvia expressed loving being pregnant and loving her body more than she ever had despite her gestational diabetes and the self control she had to exercise to provide a safe in utero environment for her baby. She stated that when she looked in the mirror she liked her image and hadn’t felt that way in a long time. When it came to giving birth and going into labor, Sylvia talked in the group about her resistance to giving birth. She did not want to not be pregnant. She wanted to keep her baby inside of her. Due to her gestational diabetes it was possible that she may have her baby a few weeks early. This was not the case for Sylvia. She was two weeks late in delivering her baby and needed to be induced. When she went to the hospital, she was in labor for 48 hours and needed three epidurals. Sylvia’s wish to keep her baby inside perhaps was very much at play and giving birth disrupted the fusion she wished to maintain with her baby. Since the birth of her baby, Sylvia has expressed very high body dissatisfaction and a strong unwillingness to make any adaptable changes like the ones she made during pregnancy. Her resistance may be related to having wanted to stay pregnant. Sylvia may have something inside of her that she has yet to find words to express.

The curative effects of speaking about ones’ pregnancy experience

The pea to a pumpkin group process of finding one’s words makes possible a communication within each group member’s dissociated parts of each of their inner worlds. This process has strengthened each of the women’s more tenuous sense of reality by weaving together various parts of each of their personalities to form a more cohesive fabric. Each woman has the chance to understand not only what happened in their past but also how events from their past have become the template for organizing internally all subsequent experiences, in this case, pregnancy and motherhood. By conducting the pea to a pumpkin group in this way, meaning for each of these women and their histories of eating disorders is constructed out of what could be overwhelming chaos. Words become the means for expressing and regulating affect.

The power of the pea to a pumpkin group demystifies destructive behaviors and decreases shamefulness and allows these mothers to appreciate the adaptive aspects of their eating disorders, mood concerns and traumatic attachment issues. Working through the enactments in a group setting and understanding them enables both the mothers and the therapist to know through experience that each can feel whatever they may feel with the other without destruction of the relationships and abandonment. Even intense emotion can be contained. The group is both supportive and mutative. For example, I made an offhanded comment regarding Terri’s OCD tendencies with her baby and she returned the following week and expressed to me calmly that she was angry, hurt and confused by my comment. “I didn’t know I had OCD tendencies.” This led to an open discussion in the group that began with me apologizing for hurting Terri’s feelings in any way. This then led to a discussion about anxiety, OCD and Terri’s wish to not treat her baby the way she was treated: neglected and uncared for. While at the same time, we could explore her over compensatory and intense reaction to her baby becoming ill and how this reaction may also be accommodating to her needs rather than her baby’s needs. Terri did not want to feel sad or responsible for her baby being sick. There was a resolution and understanding.

The psychoeducational aspect of the pea to a pumpkin group can help members to recognize and identify certain attachment patterns, behaviors and emotions while providing links between their eating disorder and attachment with their mother and developing attachment with their infant. This group develops a common history together of being pregnant and having their babies. They each identify with me, not as harsh and punitive as they are to themselves. They also see themselves in each other, a powerful means for altering their own attitudes and feelings toward themselves. There becomes a greater capacity for self reflection when eating disorder behaviors diminish and the focus of the group can shift to one that is more interpersonal and psychodynamic, geared toward attachment and becoming a mother.

The pea to a pumpkin group becomes an alternate family as they move through their pregnancies and become mothers and become better mothers to themselves and to each other. Combined with individual therapy the holding environment is greatly expanded. This a powerful tool for change and it allows for delicate interpretations to occur using prior knowledge from individual work. The pea to a pumpkin group eases aloneness and allows trust to develop over the lifetime of the group. All the members of the group report feeling alone at times and how the group has substantially helped fill this void. The group has also been a place where each member can explore the feeling of being alone.

The pea to a pumpkin group developed cohesion that was promoted through identification with each other and the common goal of developing the capacity to move through pregnancy with emotional regulation, awareness and develop the most possible healthy attachment with their babies. This cohesion has led to these women continuing their group therapy with their babies! Each week we meet, three mothers and three babies, each born one month apart in tandem, and so the story will continue.

Even with all of their struggles, these women maintained a sense of hope for a full life and family. The Pea to a Pumpkin Group developed out of this sense of hope and wish for ongoing growth and a sense of peace and freedom. In closing, I wish to quote S. Louis Mogul, M.D., who authored a paper “Sexuality, Pregnancy and Parenting in Anorexia Nervosa.” He ends the paper with a beautiful and poignant paragraph that resonated with me and the intention of the pea to a pumpkin group.

“Most clinicians who know patients with anorexia nervosa are impressed with how completely love relationships, and, even, loving feelings are squeezed out of the patients’ lives as the disease progresses and the whole emotional life becomes focused on food and body weight. Even in the phase of recovery from weight loss many anorectics are still too preoccupied with these to experience real loving feelings. It is the argument of this paper that the powerful, even if narcissistic, experience of falling in love with a baby and a child can provide, in some cases, an opening for the anorectic in therapy to be active in restructuring the sense of self based on a new, positive mother – child relationship that is, probably, in turn based on the parallel experience of finding a positive relationship in the therapy. The patient needs the capacity, often impaired anorectics, for a strong investment in building and using a positive therapeutic relationship – stronger than the investment in thinness. The therapist needs to be able and willing to foster the growth of such a relationship and help the patient find the opportunity in being a good parent of mastering some of the specific deficits and conflicts that are central in the psychotherapy of anorexia nervosa.”

Mogul, Louis S., “Sexualtiy, Pregnancy and Parenting in Anorexia Nervosa,” Psychoanalysis & Eating Disorders. Bemporad, Jules R. MD & Herzog, David B. MD, 1989; The American Academy of Psychoanalysis.

Pregnancy and Eating Disorders

By Maggie Baumann, LMFT, CEDS

As I am preparing this article on pregnancy and eating disorders, it’s a topic I am very familiar with for a number of reasons:

1.  I am in the process of writing a chapter on “Eating Disorders During Pregnancy” in collaboration with other chapter authors for a treatment book featuring eating disorders in special populations entitled An Integrative Psychological, Medical, and Nutritional Approach to the Treatment of Eating Disorders, with an expected print date of 2017.*

2. Almost 30 years ago, I was a pregnant woman with an eating disorder and I lived silently, with not a soul knowing.

I have two daughters, and it was my second pregnancy I struggled the most with my anorexia. My second daughter is now a healthy 28-year-old, yet she was not unscathed by living in the womb of a pregnant mom restricting calories and excessively exercising.

I spoke to this daughter as I was trying to prepare this article in the midst of being a daughter myself supporting my 83-year-old mom dying from emphysema.

My daughter understood the pull I was experiencing to share this important, and personal, topic to the eating disorder community and balancing my dedication to my mom.

My daughter said, “Mom, have you ever heard of Buzzfeed?” She added, “Write the article highlighting the topic in an easy to read, user friendly format.”

How lucky am I to have this daughter alive for her to share her wisdom with me. I loved her idea and it allowed me the balance I needed as I was preparing this article between my professional and personal worlds.

Popular Q & A on Eating Disorders and Pregnancy

Q1: How can an eating disorder history or diagnosis impact fertility?

A: The loss of periods and irregular periods often occur in girls and women struggling with eating disorders. This can impact fertility and the ability to conceive a child. It’s also important to understand that ovulation and pregnancy can occur in absence of menses.

In some women with anorexia, lack of menstruation does not mean she is infertile. Ovulation can still occur resulting in a pregnancy while the woman may believe she is protected from getting pregnant.

Pregnant women with BED usually have higher BMI’s and can have more difficulty conceiving compared to normal weight women.

According to recent research, 76.4 percent of infertility patients did not report current or past eating disorder to their infertility health care provider.

Q2: How might pregnancy trigger an increase of eating disorder symptoms?

A: Pregnancy can cause “out of control feelings” in women with a history of, or active eating disorders — triggering an increase in eating disorder behaviors such as calorie restriction, bingeing, purging and obsessive exercise.

The loss of control to a woman’s body shape/size, weight, appetite and mood can be destabilizing to some women at risk for eating disorders during pregnancy.

Another trigger — often the first thing pregnant women are exposed to in obstetrician’s office is the scale. This can cause intense fear for those patients with eating disorders.

Pregnancy hormonal fluctuations, an increase in anxiety and in marital stress also play roles in why some women may feel this loss of control and the need to use the eating disorder as a coping tool during pregnancy.

Q3: What are some of the medical complications of eating disorders during pregnancy?

A:  Complications for pregnant mothers can include cardiac problems, miscarriage, gestational diabetes, premature birth, labor problems, preeclampsia, and breech presentation and increase C-sections.

Potential complications for the fetus/baby can include low birth weight, IUGR (Intrauterine Growth Restriction), respiratory distress, large for gestational age infants for those women with BN/BED, cleft palate, microcephaly (abnormally small circumference of fetus/baby’s head), blindness, learning disabilities (including ADHD) and mood disorders later in life.

Q4: How might women with eating disorders experience a pregnancy psychologically?

A: For many women with active eating disorders during pregnancy, depression, anxiety and disconnection or lack of attachment to the fetus/baby are common.

It is also known, depression in the mother can also negatively affect the baby in utero. Antidepressants can be safely given to pregnant women in high-risk cases to help improve the mood of the mother and the environment of the developing baby.

On the flip side, some women with active eating disorders prior to pregnancy report cessation of behaviors and feelings of joy during pregnancy. Some women can maintain recovery in postpartum. However, even among women who experience a remission of eating disorder symptoms during pregnancy, a large percentage will relapse within six months postpartum.

Pregnancy is not a treatment for eating disorders. A formalized treatment plan is recommended for all women so the underlying causes of the eating disorder can be identified and successfully treated.

Q5: How can pregnancy influence body image in women with eating disorders?

A: Fears of an increase in body shape/weight can cause women to engage in restrictive eating with increased anxiety over self-image.

Today “Baby bump” comparisons to celebrities is a factor media publicizes, influencing normal pregnant women (with and without eating disorders) to believe a small size stomach is healthy, not dangerous.

Q6: What are some guidelines for women with eating disorders to follow when they learn they are pregnant?

A: It is most important for women to share with their OB that they have an eating disorder or history of an eating disorder. This gives the obstetricians the red flag to monitor the pregnancy with special precautions.

It’s also essential for pregnant women with eating disorders to work with a collaborative treatment team with expertise in eating disorders care. The eating disorder team can include the OB or perinatologist (on obstetrician trained to treat high risk pregnancies), therapist, dietitian and psychiatrist, if needed.

Many pregnant women carry shame about their behaviors that they know can be harmful to their babies and don’t share their eating disorder information to their obstetricians. Obstetricians who are knowledgeable about eating disorders and sensitive to these patients can use the SCOFF questionnaire that can help women feel more safe and, therefore, more likely to disclose their history and experience with their disorder.

Q7: How can an eating disorder diagnosis impact a woman’s ability to nourish her baby?

A:  If a woman struggles feeding herself due to her eating disorder, this can transmit to poor nourishment to her baby in utero and after the baby is born. Some pregnant women with a history, or active, eating disorder can let go of the harmful behaviors to allow healthy nourishment for herself and her baby. Oftentimes, moms feel pregnancy is a time during which eating is “allowed” because the purpose is for the baby’s health.

An excess of calories, though, can cause other problems. For women with BN or BED, too many calories can cause overweight babies at delivery and increase the risk of gestational diabetes in the pregnant mother.

Q8: How might an eating disorder impact a new mother’s ability to connect with or care for her baby?

A: The bonding of a pregnant mother and infant starts in utero. Peri/Postnatal depression negatively affects the mother’s ability to securely bond to her baby. The depression makes her less “present” to her body and to the baby growing inside.

Preoccupation with weight loss during the pregnancy and postpartum, along with researched statistics showing moms with eating disorders experience shorter breastfeeding time interferes with the mother physically and emotionally connecting to her baby. This poor attachment can have lasting negative affects on the relationship of mother and child, and to the child’s development, even into adulthood.

Q9: What influences the shame that many pregnant women with eating disorders experience?

A: Shame can come internally from pregnant woman when the severity of her eating disorder overrides an honest wish to nourish her baby. The cycle of the behaviors can overwhelm the mother and can prevent her from making health decisions for herself and her fetus/baby.

External criticism also contributes to the shame pregnant women experience from public and family members on “not caring for the baby’s health.” This shame can influence a pregnant woman into silence about her disorder.

Q10: Do you have any specific treatment recommendations for clinicians treating pregnant women with eating disorders?

A: It is most important to work with a multidisciplinary eating disorder treatment team including: OB/perinatologist, therapist, dietitian, lactation consultant and, if needed, a psychiatrist.

This treatment team needs to understand the core issues of how and why eating disorders develop in the first place and that a pregnant woman with an eating disorder can struggle from anorexia, bulimia or binge eating (or combination of).

Treatment by a therapist should focus on coping skills and promoting secure attachments/bonding to the fetus/baby in utero. Treating trauma related to the eating disorder during pregnancy can have a negative impact on the physical/emotional health of the mother and her fetus/baby.

Clinicians should understand the special needs that they are caring for two and that eating disorders during pregnancy is not a sign of weakness but of the illness.

Q11: What are resources for OB-GYNs to learn more about caring for an expecting mom with a history or current eating disorder?

A: If a provider does not have expertise in treating pregnant women with eating disorders, OB-GYNs can contact the Academy of Eating Disorders for physician referrals to those with this expertise.

Another link for obstetricians to gain more knowledge of eating disorders during pregnancy is the Obstetrical Gynecological Survey.

Q12: What resources are there for women who are pregnant who have an active eating disorder?

A: A free web-based support group for pregnant women and moms with eating disorders — called “Lift the Shame” is hosted on the 3rd Sunday of the month at 6-7 pm (CT) by Timberline Knolls Residential Treatment Center. Participants can register for “Lift the Shame” here.

In terms of dealing with body image issues and weight gain during pregnancy, the book, “Does This Pregnancy Make Me Look Fat?” by authors Claire Mysko and Magali Amadei is very helpful. The website Eating Disorder Hope has numerous articles on “pregnancy and eating disorders.”

The Language of Healing: For parents to care for and support their child who suffers from an eating disorder and self-injury.

By Amy M. Klimek, MA, LPC

Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicideThe information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.

Language of Self-Injury and ED

Self-injury and eating disorder scars tell a story, a personal history of the conflict both internally and externally on the body. This story is different from one person to the next with the one constant being, the struggle is real.

Those who suffer from inflicting pain by means of cutting or restricting, struggle with a marked inability to verbalize and process emotions. Inescapably, their bodies are used in avoidance to experience their emotions. Reaching for a part of themselves that is missing, at times they do not fully understand how to navigate their own experiences. The behaviors can be a means to disconnect from emotions due to a lack of internal resources to deal with feelings mindfully and with neutrality.

Self-injury is the result of self-inflicted pain to oneself, without suicidal intent. There is a parallel between those who struggle with self-injury and those who suffer from an eating disorder—both use the behaviors of cutting, burning, and picking – restricting, binging, or purging to control distress. These behaviors are identified as coping skills to alleviate a person’s emotional and mental suffering.

As it may be difficult to align these behaviors as a means of coping, they are in fact the person’s only resource to regulate intense feelings. Whether the behaviors are aggressive or passive, the person’s struggle needs attention and support in order to cease these destructive, at times deadly behaviors; this applies to both self- injury and eating disorders. For healing to occur, the child who is suffering and the parents must discover a new language, a new source of coping both in body and in words.

To put this in perspective, in an article written for the American Foundation for Suicide Prevention, Dr. Cynthia Bulk, Ph.D. shared, “Not all eating disorders are the same when it comes to deliberate self-harm. Individuals with bulimia behaviors who reported they had experienced more deliberate self-harm episodes were more likely to engage in violent deliberate self-harm behaviors and these destructive behaviors tended to fluctuate with their weight.”

Dr. Bulik also reported that individuals with anorexia, the restricting type, had the lowest risk of self-harm episodes while those with history of both anorexia and bulimia were at the highest risk. The relationship between the two behaviors, eating disorder and self-injury, indicates an undeniable need to support the person who is suffering.

The objective is not supporting the notion of “more” or “fewer” serious self-destructive acts. Any acts of self harm including eating disorders, addictions, and all forms of self-mutilation are “significant “ when they sustain feelings of guilt and shame, cause distress in relationships, create defensives, or encourage lying as well as foster emotional, physical, and psychological pain.  -Excerpt from “Letting Go of Self-Destructive Behaviors” by Lisa Ferentz

Language of Support

Support can be reached for both parties when viewed through the same lens. Enabling the individual to express a whole self so that authenticity and connection to others can emerge is the best means to achieve this support.

It is incredibly overwhelming, frustrating, and discouraging for a parent to stay calm while watching a child engage in these terrifying behaviors. It may appear that the correct approach is to “STOP” the behavior, make the child disengage from the cutting, restricting, burning, or purging; regrettably, this is not the right answer. Rather, it is honoring the child’s experience as described by the child without assumptions or historical perceptions about the struggle and behaviors.

Creating a supportive environment is not safeguarding the physical environment by removing all the sharp objects or binge foods in the hope that your child will not engage in the behaviors. The pull of the struggle is strong; the child will find ways to engage in behaviors if he/she does not feel safe internally.

This is not to say you should ignore the physical environment. There are ways to alter the surroundings without trying to create a fragile environment for the child.

It may be helpful in early recovery to not have certain foods in the house or sharp objects in sight. Your child may ask for specific support such as bathroom monitoring or reassurance that he/she is following the meal plan. Your child may ask you to remove objects that he/she might be enticed to use again if available. Both you and your child will learn how to acclimate to this new environment with the help of therapy and support.

Remember, you are the parent, not the police. Watching your child’s every move may appear as if you only care about stopping the behaviors and not about the suffering itself. The “policing” of behaviors can place a barrier between you and your child, and is exhausting for both.

While it is impossible to safeguard your child’s experience, you can validate it. Validation does not mean that you completely agree with your child or the reasons of their experience; rather, it is hearing and honoring what your child is saying either with words or in body language.

Validation is inherently nonjudgmental. Be curious with your child; invite him or her to describe the experience. At times, words are inadequate and the unspoken words can speak louder through the language of the body.

Language of Healing

As you are acquiring a new perspective regarding what you can do, how you can care for and support your child, you will gain an understanding of the function of the behaviors.

Your role is to facilitate change. This starts with change within you. Both you and your child will need to acquire new language as well as a new set of tools to respond to the thoughts and feelings that are creating distress. You will not always have the right answers or the ideal approach. You are not supposed to; you are a parent, not a trained clinician. The simple hope is you will find another way to react, responding differently each time.

Supporting your child is having trust in the process. Through the process, you will find new ways to speak and listen to your child, along with new ways to experience your own feelings about the behaviors. Communication should be without condemnation or judgment. It is the language of acceptance towards the present moment.

Both parties will be called upon to exercise collaborative communicating and empathic listening, which are necessary in the therapeutic relationship. The practice of transparency in relationship to healing implies open communication and vulnerability. This is working towards surrendering the familiar response of escaping from the experience. Building present moment resilience honors the emotions, it is to be mindful of the judgements that show up, and not attach oneself to that experience. This creates more opportunity to heal and recover.

Recovery does not occur all at once. You are not intended to learn all new skills immediately, since it takes practice and patience to respond to emotions. Being patient is not synonymous with doing nothing. This is a journey, a path towards healing, self-reflection, and individuality. This journey requires cultivating an attitude of willingness to change a lifestyle that once compromised the authenticity of the self.

Throughout the journey you may question yourself.  Do so mindfully, with care, kindness, and curiosity, knowing that the two of you are learning and growing together.

About the Author -

Amy M. Klimek, MA. LPC, Eating Disorder Program Coordinator Timberline Knolls Residential Treatment Center, Lemont, Ill.

Amy has worked in the behavioral health field for five years. She received a Bachelor of Science Degree in Sociology from the University of Illinois in 2006. She subsequently earned a Master’s Degree in Counseling, specializing in both community and school counseling from Lewis University in 2010.

Amy is the Eating Disorder Program Coordinator at Timberline Knolls Residential Treatment Center in Lemont, Ill. In this position, she supervises the Eating Disorder Specialists Team, offers support through training to other staff, and provides education on eating disorders to the community. As a clinical professional counselor she works individually with residents and families to educate and support the healing process of recovery.  Amy is a member of The International Association of Eating Disorders Professionals Foundation.

Amy is currently completing a 200 hour yoga certification training to facilitate mind and body connection in the healing process of recovery. The certification will contribute to her work with residents in the expressive therapy component of the Timberline program. Through yoga, she hopes to create balance in the mind and body through movement, breathing, and meditation.

Resources -

American Foundation for Suicide Prevention (Aspg.org)

Article written Dr. Cynthia Bulk, PHD “Not all eating disorders are the same when it comes to deliberate self-harm”

https://www.afsp.org/research/research-connection/not-all-eating-disorders-are-the-same-when-it-comes-to-deliberate-self-harm

Letting Go of Self-Destructive Behaviors: A Workbook of Hope and Healing 1st Edition written by Lisa Ferentz (2015) Letting Go of Self-Destructive Behaviors offers inspiring, hopeful, creative resources for the millions of male and female adolescents and adults who struggle with eating disorders, addictions, any form of self-mutilation.

When the Eating Disorder Client Is Suicidal

By Nicole Siegfried, Ph.D, CEDS

Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.

Eating disorders are associated with extremely elevated mortality rates (Chesney, Goodwin, & Fazel, 2014). Although many of these deaths are related to medical complications from the disorder (e.g., arrhythmia, stroke), a significant percentage are due to suicide (Arcelus, Mitchell, Wales, & Nielsen, 2011; Crisp, Callender, Halek, & Hsu, 1992; Fedorowicz et al., 2007; Harris & Barraclough, 1997). In fact, individuals with anorexia are 31 times more likely to make a fatal suicide attempt than the general population (Arcelus et al., 2011; Chesney, et al., 2014; Preti, Rocchi, Sisti, Camboni, & Miotto, 2011), and individuals with bulimia nervosa are seven and a half times more likely to die by suicide than the general population (Arcelus et al., 2011; Chesney et al., 2014; Preti et al., 2011). Additionally, rates of death by suicide among individuals with eating disorders are elevated compared to other mental health disorders, including depression, bipolar disorder, and schizophrenia (Chesney et al., 2014).

Conceptualizing Suicide in Eating Disorders

An understanding of suicidality and how it develops in individuals with eating disorders is necessary for clinicians to effectively treat clients with eating disorders. Many clinicians have misconceptions about suicide in eating disorders and mistakenly attribute the high suicide rate to clients’ fragility and compromised medical condition. Other providers have the misconception that individuals with eating disorders develop eating disorders as a death wish or as a way to slowly kill themselves. Clinicians should have a clear understanding of the myths and facts related to suicide and eating disorders to be able to provide effective assessment and intervention (see Table 1). Additionally, clinicians who treat eating disorders need to have a clear understanding of the suicidal mind and a framework for conceptualization of suicidality in eating disorders.

Suicide as Psychache

According to Shneidman (1996), “psychache,” which is defined as an overwhelming psychological pain, is at the root of suicidality. This psychological pain can best be understood as an amalgamation of fear, shame, anxiety, rejection, guilt, sadness, burdensomeness, disconnection, hopelessness, and other negative emotions. The profound pain associated with psychache results in an inability to effectively problem-solve, seek alternate solutions, or imagine a future. Psychache is also associated with difficulty eating, sleeping, working, and soliciting help from others (Schneidman, 1993). Psychache is so debilitating that the person experiencing it would rather endure the physical pain of death to relieve the psychological pain of psychache.

Interpersonal Psychological Theory of Suicide

Expounding on Schneidman’s theory of psychache, Joiner (2005) proposed The Interpersonal Psychological Theory of Suicide (IPTS). According to Joiner’s theory, psychological pain results from a combination of perceived burdensomeness and thwarted belongingness, which result in suicidal desire. Suicidal capability is the result of an acquired sense of fearlessness toward death and tolerance of physical pain. The intersection of suicidal desire (burdensomeness, thwarted belongingness) and suicidal capability (fearlessness toward death and pain tolerance) creates a perfect storm that can lead to a fatal outcome (see Figure 1).

The IPTS model provides a compelling framework for understanding suicide in eating disorders, and has received preliminary empirical support in various studies (Crow et al., 2008; Selby et al., 2010; Smith et al., 2013). Individuals with eating disorders may develop perceived burdensomeness based on their perception of the impact of their disorder on their families. Carrying the psychological pain associated with psychache can also create a level of burdensomeness for individuals with eating disorders. Finally, clients with eating disorders often report burdensomeness based on the demands of treatment and recovery. For example, gaining weight, working through trauma, or experiencing emotion can create a level of burdensomeness that feels intolerable. Individuals with eating disorders also report thwarted belongingness. They report feeling isolated from others, detached from their identities, and disconnected in mind, body and soul. Capacity for suicide in eating disorders develops through the use of eating disorder behaviors. Based on the lethality and violence associated with vomiting, severe restriction, hard exercise, and/or diuretic/laxative use, eating disorder clients may develop a fearlessness of death while heightening their pain tolerance. Other violent behaviors, such as self-harm and substance abuse, which are common in eating disorders, may further amplify the capacity for suicide. The usefulness of the IPTS model in conceptualizing suicidality in eating disorders may also be helpful in guiding assessment and intervention.

Suicide Risk Assessment

In general, mental health providers are poorly trained to assess suicide risk. The majority of graduate programs provide less than four hours of formalized training in suicide assessment (Schmitz et al., 2012), and a large number of clinicians conduct inadequate suicide assessment or fail to detect suicidal ideation in their clients (Bongar, Maris, Berman, & Litman, 1998; Simon, 2002). Based on the high rate of suicide in eating disorders, lack of training and incompetence in suicide assessment is particularly concerning. To date there are no known investigations of competence in suicide risk assessment for eating disorder clinicians, but it seems reasonable to assume that there is a similar lack of training to that of mental health providers. Based on the high rate of suicide in clients with eating disorders, it is recommended that clinicians treating eating disorders receive specialized training in suicide assessment and intervention.

Suicide Risk Assessment: What Not to Do.

Self-Report Checklists. Despite the frequent use of self-report suicide risk checklists in clinical settings, they have not been found to demonstrate the comprehensiveness or accuracy to adequately predict suicide risk. As such, they are not recommended to be used in isolation when assessing suicide risk in eating disorder clients. In addition to a self-report checklist, it is necessary to conduct a more comprehensive and integrative clinical assessment with each client to accurately determine suicidal risk.

No-Suicide Contracts. Along similar lines, it is also fairly common for clinicians to routinely utilize no-suicide contracts (Miller, Jacobs, & Gutheil, 1998), which require clients to agree that they will not engage in suicidal behavior. To date, there is no evidence that no-suicide contracts actually prevent suicidal behavior (Joiner, Van Orden, Witte, & Rudd, 2009). In fact, in one study up to 50% of individuals who had died by suicide had signed a no-suicide contract (Kroll, 2000). Additionally, there has been no legal precedent in which a no-suicide contract has protected clinicians in litigation (Simon, 1992). Furthermore, there is evidence that the use of no-suicide contracts creates a false sense of security for clinicians, and interferes with their ability to conduct a comprehensive and accurate suicide risk assessment (Simon, 2002). Based on these findings, other methods of assessment and intervention are recommended.

Suicide Risk Assessment: What to Do.

Comprehensive Suicide Assessment. Several methods of comprehensive suicide risk assessment have been proposed (See Joiner et al., 2009 for a full discussion of these measures). In this article one method of evidence-based risk-level assessment and intervention is presented that may be helpful for clinicians treating eating disorder clients. The Suicide Risk Decision Tree (Joiner, Walker, Rudd, & Jobes, 1999) assesses three main indicators of suicide risk (i.e., past suicidal behavior, current suicidal desire/ideation, and current resolved plans and preparations), as well as additional risk and protective factors. The Suicide Risk Decision Tree (see Figure 2) is a semi-structured integrated interview, which requires appropriate clinical training to appropriately and accurately determine suicidal risk. The risk assessment framework assesses for past suicidal behavior, which has been identified as the most significant predictor of future suicide attempts (e.g., Putnins, 2005) and death by suicide (e.g., Brown, Beck, Steer, & Grisham, 2000). The interview also assesses Suicidal Desire and Ideation (i.e., relatively vague thoughts about wanting to be dead) and Resolved Plans and Preparations (i.e., more specific thoughts about and planning for a suicide attempt). The endorsement of additional risk factors (e.g., stressors, feelings of hopelessness) may increase risk. Protective factors (e.g., increased social support) are also assessed, and may buffer risk for suicide. The information obtained in the clinical interview is utilized to categorize suicidal risk into low, moderate, and high risk, using the flow chart from Figure 3.

Risk-Level Interventions. The Suicide Risk Assessment Decision Tree provides a fairly straightforward method to assess suicide risk and offers a framework to guide interventions based on risk level (see Figure 4). For clients who are at low or mild risk, it is recommended that the clinician help the client create a coping card or a de-escalation plan to address suicidality that may arise during the course of treatment. A common format includes: “If I should become suicidal, these are the actions I will take and the coping skills I will utilize.”

For individuals who are at moderate risk, the use of a safety plan is recommended. A safety plan (see Figure 5) is typically more detailed and specific than a coping card or de-escalation plan and differs from a no-suicide contract in that it focuses on what the client will do as opposed to what the client will not do. The traditional safety plan can be enhanced by including reduction of access to means. Research shows that reducing access to means is one of the most effective interventions for preventing suicide (Sarchiapone, Mandelli, Iosue, Andrisano, & Roy, 2011). Including reminders of reasons for living can also enrich the safety plan. As a function of the constricted thinking, clients who are suicidal often have difficulty accessing reasons for living. Research has shown that recalling reasons for living during a suicidal crisis can decrease suicide risk (Rudd et al., 2015).

For individuals at high suicide risk, the same methods of safety planning and means reduction that are used for moderate suicide risk are recommended. For individuals at high risk, an assessment of imminent harm is necessary. For those individuals at imminent risk, psychiatric hospitalization may be necessary to provide safety. It is recommended that clinicians seek consultation when making decisions for moderate and high risk clients and that they document reasoning behind which methods of intervention were chosen and not chosen.

Conclusion

Based on the high rate of suicide in eating disorders, it is imperative that eating disorder clinicians have a good understanding of suicide in this population and demonstrate competence in assessing and treating suicidality. Evidence-based suicide risk level determination can guide eating disorder clinicians to appropriately intervene with suicidal clients to provide effective treatment and ultimately save lives.

Table 1. From: Joiner, T. (2010). Myths About Suicide. Cambridge, MA: Harvard University.

Copyright 2010 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.

MYTHS AND FACTS ABOUT EATING DISORDERS (EDs) AND SUICIDE

MYTH #1 EDs are really a slow suicide	FACT #1 EDs are characterized by a desire for thinness and to not feel rather than a desire for death.
MYTH #2 Individuals with AN are less likely to choose violent methods of suicide because these individuals tend to be harm avoidant	FACT #2 Although individuals with AN demonstrate harm avoidant tendencies, they have become habituated to bodily damage which overrides harm avoidant nature.
MYTH #3 Individuals with ED's are more likely to die by suicide because they are medically compromised.	FACT #3 Individuals with EDs are more likely to die by suicide attempt because they utilize more lethal means in an attempt.
MYTH #4 Individuals with EDs tend to attempt suicide because they have more selfish traits than individuals with other disorders.	FACT #4 Individuals with or without EDs who attempt suicide tend to do so to relieve their perceived burden on others, rather than as a selfish act.
MYTH #5 Individuals with EDs are more impulsive and therefore more likely to make an impulsive decision to die by suicide.	FACT #5 Most suicides are the result of long planning and deliberation - with or without an ED.
MYTH #6 The majority of people with or without EDs who have thoughts of suicide will attempt suicide at some point.	FACT #6 The majority of individuals with suicidal thoughts do not attempt or die by suicide.
MYTH #7 There is an increase of suicides around the winter holidays.	FACT #7 The most common time of the year for suicides is during the spring.
MYTH #8 Suicide attempts are just cries for help or to get attention.	FACT #8 Individuals who attempt suicide are experiencing true psychological pain, and are unable to articulate their pain and ask for help.

Figure 2. Decision Tree Interview. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 72. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.

Trigger warning/Stress warning: Triggers can be unique, inconsistent and unpredictable. Content in this article may be “triggering.” Content warning: self-harm, suicide
The information contained in this website is for general information purposes only. In no event is Gurze/Salucore liable for any loss or damage, including without limitations, indirect or direct or consequential loss or damage, or any loss or damage whatsoever arising from the use of this website. Use of the information posted is at your own risk.To be used by a trained clinician only -

Assess History of Suicidal Behavior:

1. Past suicidal behavior: Have you attempted suicide in the past? How many times? Methods used? What happened (e.g., went to hospital?).
2. Do you have a history of non-suicidal self-injury? (e.g., burning, cutting, etc.)

Assess Suicidal Desire and Ideation:

1. Have you been having thoughts or images of suicide?
2. Do you ever think about wanting to be dead?
3. Frequency of ideation: How often do you think about suicide?
4. What reasons do you have for dying? What reasons do you have to continue living?

Assess Resolved Plans and Preparations:

1. Duration [look for pre-occupation]: When you have these thoughts, how long do they last?
2. Intensity: How strong is your intent to kill yourself? (0 = not intense at all, 10 = very intense)
3. Specified plan [look for vividness, detail]: Do you have a plan for how you would kill yourself?
4. Means and opportunity: Do you have [the pills, a gun, etc.]? Do you think you’ll have an opportunity to do this?
5. Have you made preparations for a suicide attempt? [e.g., buying pills]
6. Do you know when you expect to use your plan?
7. Courage & competence: How scared do you feel about making an attempt? How courageous do you feel about making an attempt? How able do you feel to make an attempt?

Assess “other significant findings”:

1. Precipitant stressors: Has anything especially stressful happened to you recently?
2. Hopelessness: Do you feel hopeless?
3. Impulsivity: When you’re feeling badly, how do you cope? Sometimes when people feel badly, they do impulsive things to feel better. Has this ever happened to you? [e.g., drinking alcohol, running away, binge eating]
4. Has anyone in your family made a suicide attempt or died by suicide? Relationship to you? Thoughts and feelings about this?
5. Presence of psychopathology (rated by interviewer)
6. Thwarted belongingness: Do you feel connected to other people? Do you live alone? Do you have someone you can call when you’re feeling badly? [are supportive relationships completely absent?]
7. Perceived burdensomeness: Sometimes people think: “The people in my life would be better off if I were gone.” Do you think that? In what ways to you feel like you contribute meaningfully to those around you? (e.g., at work, at home, in the community)

Protective Factors:

1. Adequate social support (use responses to item 6 (assess “other significant findings”) to assess this)
2. Responsibility to others (use responses to item 7 (assess “other significant findings”) to assess this)
3. Good problem-solving ability: When you are experiencing distress, what do you do to resolve it? When you encounter something difficult, do you sometimes feel like you have no idea what to do to get through it?
4. Cultural and religious beliefs against suicide

Figure 3. Suicide Risk Assessment Decision Tree. Adapted from “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner Jr., R. L. Walker, M. D. Rudd, & D. A. Jobes, 1999. Professional Psychology: Research and Practice, 30, p. 451. Copyright 1999 by the American Psychological Association. Reprinted under APA’s fair use policy.

Figure 4. Interventions for each level of suicide risk. Adapted From The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients, by T. E. Joiner, Jr., K. A. Van Orden, T. K. Witte, and M. D. Rudd, 2009, p. 106. Copyright 2009 by the American Psychological Association (APA). Reprinted under APA’s fair use policy.

Risk Category (circle one and check off each action taken):

Low Risk (actions taken)

• Create a coping card with the client that includes a variant of the following, “In the event that you begin to develop suicidal feelings (or if your existing feelings become more intense), here’s what I want you to do:”
• List at least three pleasant activities that a client could realistically do when feeling distressed (e.g., work on crossword puzzles, listen to soothing music)
• List two or three people from the client’s support network that could be called (e.g., mother, friend)
• List emergency numbers (including that for the National Suicide Prevention Lifeline; 1-800-273-TALK and 911)
• Continue to regularly monitor suicide risk
• Document all activities in progress notes

Moderate Risk (actions taken)

• Consult with a supervisor if you are a trainee
• Create a coping card (see above)
• Consider midweek phone check-ins to assess suicide risk more frequently
• Inform about existence of adjunctive treatments (e.g., medication)
• Increase social support:
• o   Encourage client to seek support from friends and family
• o   Plan with client to have someone check in on him or her regularly
• o   Ask client’s permission for you to contact the person who will be checking in
• Attempt to remove access to lethal means (e.g., firearms, pills, etc.)
• Ask for permission to speak with an informant (e.g., family member, romantic partner), with the appropriate release
• Continue to regularly monitor suicide risk
• Document all activities in progress notes                       

High Risk (actions taken)

• Consult with a supervisor if you are a trainee or with a colleague if you are not a trainee
• Consider emergency mental health options (e.g., hospitalization)
• Client should be accompanied and monitored at all times
• If hospitalization is not warranted, use suggestions from the Moderate Risk category
• Document all activities in progress notes (including documentation that hospitalization was at least considered)

Figure 5. Sample Safety Plan. Adapted from Bartlett, M. & Siegfried, N. (April, 2012). Bridging the treatment of eating disorders and suicidality. Workshop presented at the Annual Conference of the American Association of Suicidology in Baltimore, Maryland. 

Safety Plan

• When I start to feel emotionally distressed or feel like I want to hurt myself or kill myself, five things that I can do to soothe myself and manage my feelings and/or urges are:

• When I start to feel like I might act on an unsafe behavior (e.g., self-harm, suicidal behavior), five things I can do to prevent the behavior are: 

1. Create a safe environment:

_________________________________________________________________________

_________________________________________________________________________

2. Remind myself of at least 2 reasons for living and recovering:

________________________________________________________________________

________________________________________________________________________

3. ______________________________________________________________________

4. ______________________________________________________________________

5. ______________________________________________________________________

• I agree that after I have followed through on the above coping skills, if things are still difficult for me and I believe I might hurt myself, I will do the following:

1. If I am at the facility, I will inform a staff member, who will assist me in being safe.

2. If I am away from the facility, I will

Call the National Helpline: 1-800-273-TALK

Or Contact the local police (phone number): ________________________________

Or Go to the nearest emergency room ____________________________________

This article was adapted from a previous article: Bartlett, M. L., Siegfried, N., & Witte, T.K.  (2013).  Best practice clinical interventions for working with suicidal adults.  Alabama Counseling Association Journal Special Edition Suicide Prevention, Intervention, and Postvention with Youth, Adults, and the Elderly, 38, 65-79.  

About the author -

Dr. Nicole Siegfried is a Certified Eating Disorder Specialist (CEDS) and a licensed clinical psychologist. She is the Clinical Director of Castlewood at The Highlands Treatment Center for Eating Disorders in Birmingham, AL. She previously served as an Associate Professor of Psychology at Samford University and is currently Adjunct Associate Professor of Psychology at University of Alabama at Birmingham. She is an international speaker and has published research, magazine articles, and book chapters in the field of eating disorders. Presently, Dr. Siegfried is an investigator on a research study with Dr. Thomas Joiner examining resilience and suicidality in eating disorders. She is president of the Alabama Regional Chapter of IAEDP, which is in the formation stages. She is a member of the Academy of Eating Disorders (AED) and Co-Chair of the Eating Disorders and Suicide Prevention AED Special Interest Group.

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