May 31, 2013 by Deanna James, LPC, CEDS in Clinical ArticlesWritten by Nicole Siegfried, Ph.DI am delighted to join the Castlewood team in opening an affiliate center in Birmingham, Alabama. The Highlands Treatment Center for Eating Disorders is set to open this July and will provide Partial Hospitalization, Intensive Outpatient, and General Outpatient services to males and females ages 18 and older. We plan to expand services to adolescent males and females in January 2014. The Highlands will provide the same evidence-based and compassionate care associated with Castlewood facilities, and will incorporate a multi-disciplinary team that has worked together for several years in the treatment of eating disorders.
I have treated eating disorders for over 15 years in various settings, including residential, partial hospitalization, and outpatient. Several years ago while working in residential care, I was struck by the prevalence of acute and chronic suicidality in our population of adult females with eating disorders. Although I specialized in eating disorders and had basic training in suicide assessment and treatment, I wanted a better understanding of this phenomenon and better skills for intervention. I began consulting with leading suicidologists, Dr. Mary Bartlett, Dr. Thomas Joiner, and Dr. Tracy Witte, which allowed for collaboration in training, research, and treatment as well as the development of a specialization in the relationship between suicidality and eating disorders.
Eating disorders have the highest mortality rate of any psychiatric disorder. Some research suggests that the majority of deaths in eating disorders may be a function of suicide rather than medical complications. Despite these sobering statistics, over 50% of clinicians fail to adequately assess for suicidality and the majority of practitioners have had less than two hours training in assessing suicidality (Berman, 1983; Kleespies et al., 1993).
What Not To Do in the Assessment of SuicidalityOne-Time Assessment: Many clinicians have been trained that suicide risk assessment involves a one-time question about suicidality asked at the beginning of treatment. This oversimplification is insufficient and possibly dangerous. The most common reasons for this failure to assess suicide risk include concerns that the discussion of suicide with vulnerable clients could make the idea of suicide seem more appealing, and therefore increase danger and/or that routine screening could increase risk for legal liability on the part of counselors (Lang, Uttaro, Caine, Carpinello, & Felton 2009). Regarding the former of these concerns, there is fairly compelling evidence across multiple research studies that the act of suicide risk assessment does not appear to elevate risk even among vulnerable populations (e.g., Reynolds, Lindenboim, Comtois, & Linehan, 2006). Regarding the latter, failing to assess for suicide risk, take action given that risk, and/or document the counselor’s actions can actuallyincrease liability. Instead of a single event, suicide risk assessment should be comprehensive and on-going in treatment of clients with eating disorders.
Self-Report Suicide Checklists as the Only Method of Assessment: Although self-report suicide risk assessment checklists are commonly found in clinical settings, these checklists have not usually been subjected to rigorous psychometric validation that provides evidence that they have any utility in predicting suicide risk. As such, they do not necessarily protect mental health providers in suicide malpractice cases when they are not combined with a comprehensive clinical suicide risk assessment (Simon, 2009). Even more importantly, with a lack of psychometric data providing evidence for their utility, these forms do not necessarily ensure the physical safety of clients. This does not necessarily indicate that such checklists have no place in counseling settings; rather, they can only be considered one tool in the counselor’s toolbox.
No-Harm/No-Suicide Contracts: To date, there is no evidence that no-suicide contracts actually prevent suicidal behavior (Joiner, Van Orden, Witte, & Rudd, 2009), and there are documented instances in which individuals who had signed a no-suicide contract have died by suicide (Kroll, 2000). Additionally, there has been no legal precedent in which a no-suicide contract has protected clinicians in liability (Simon, 1992). In sum, documenting that a client has signed a no-suicide contract without further detail regarding a comprehensive suicide risk assessment and other actions taken is not adequate to protect clients from self-harm or to protect oneself from liability (Miller et al., 1998).
What to Do in the Assessment of SuicidalityEvery-Session Assessment: In clients with eating disorders, especially those with a history of suicidality, suicide risk should be assessed during every session. This risk should be documented along with explanations of interventions based on this risk. Questions related to suicide can be integrated into the “check-in” at the beginning of the therapy session, and may follow a format such as that listed in Figure 1. A dialogue similar to that in Figure 1 allows for an integration of suicidality assessment into the weekly assessment of eating disorder behaviors and mood.
Figure 1. Therapist Dialogue with Client to Ask about Suicidality Therapist:What have your bingeing behaviors been like over the past week?Client:I binged on Saturday night, which I know is less than in the past, but I still beat myself up about it. I’ve also had a lot of urges to binge this week. I’m not sure why.Therapist: I’m curious as to what your mood has been like this past week. I know that in the past, feelings of depression kind of go along with your binges.Client:Right… that’s what is weird. I don’t think I’ve felt that down. I think my mood has actually been better. I can’t explain it. It feels more like numb than sad.Therapist:What about thoughts of death or dying this past week? I know those sometimes crop up with binges for you. Client:I did have some of those thoughts- nothing like before, but maybe thoughts like “Is this really worth it?” “Why can’t I get better?” “Maybe I’m just not meant to have a life.”… those kinds of thoughts.Therapist:How often did you have those thoughts this week?Client:Just on Saturday after the binge.Therapist:What kinds of plans came up related to those thoughts?Client:I’m not sure what you mean. If you mean like plans to hurt myself. I didn’t have those. These were more like just fleeting thoughts that kind of went away by Sunday.Therapist:Can you tell me what you think made them go away? …Client:That’s a good question. I don’t know…Comprehensive Evidence-Based Risk Assessment: Joiner and his colleagues (2007) recently developed a suicide risk assessment that addresses risk factors, protective factors, suicidal ideation, and intent. This risk assessment is simple and straightforward enough to use for crises workers on suicide hotlines and comprehensive enough to be used by clinicians in the treatment of suicidality (Joiner et al., 2007). An evidence-based assessment such as this one can guide practitioners to make risk assessments throughout treatment and apply interventions based on risk (see Figures 2 and 3).
Safety Plan: A safety plan is an alternative to no-suicide contract and focuses on what the client will do as opposed to what s/he won’t do. The safety plan includes a list of coping strategies and support sources to utilize during or prior to suicidal crises (Stanley & Brown, 2008). Most recently, I have also included in the safety plan a reference to means restriction (i.e., making the environment safe by removing potentially self-harming items/objects) and a reminder for reasons for living, as both of these interventions have been shown to be effective in the prevention of a suicide attempt (Bryan, 2011; Malone et al., 2000) (see Figure 4 for a sample Safety Plan).
Interventions for the assessment of suicidality, such as those discussed above, are utilized at The Highlands and other Castlewood centers, and it is recommended that they be incorporated into the practice of other clinicians. More comprehensive evidence-based assessment and intervention for suicide in clients with eating disorders will lead to better treatment and may ultimately save lives.
It is an honor to be working with the Castlewood team and I look forward to our collaboration in the treatment of eating disorders and helping our clients find the joy of a life worth living.
Figure 2: Joiner's Model for Risk Assessment
Figure 3: Joiner Risk Assessment Questions
Figure 4: Safety Plan