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September 29, 2022

Eating Disorders, Suicidal Ideation, and Nonsuicidal Self-Injurious Behavior

Eating disorders are serious mental illnesses that commonly co-occur with other mental disorders. Research has shown that 55–97% of people diagnosed with these illnesses are also diagnosed with at least one more psychiatric disorder. In addition, individuals with eating disorders are at a higher risk of dying by suicide in comparison to the general population (NEDC). This information highlights the importance of understanding the signs of suicidal thoughts and methods of preventing suicide in those experiencing eating disorders.

Alyssa Kalata, PhD, Clinical Training Manager for Veritas Collaborative and The Emily Program, joins us in this blog to discuss five actions you can take to reduce suicide risk when working with eating disorder patients.

5 Ways to Reduce the Risk of Suicidal Ideation and Nonsuicidal Self-Injurious Behavior

In my work providing training and consultation for clinicians, suicide and nonsuicidal self-injurious (NSSI) behavior are two of the topics clinicians most want to discuss. This is, in part, due to the fact that these topics often evoke a great deal of anxiety. Suicidal ideation, suicide attempts, and nonsuicidal self-injurious behaviors are surprisingly common phenomena among individuals in the United States, and the risk for these behaviors is significantly elevated among those diagnosed with eating disorders.

Below are five methods that can reduce the risk of suicidal ideation and nonsuicidal self-injurious behaviors in eating disorder patients:

1. Engage in Means Restriction Counseling

Of all interventions developed to prevent suicide, means restriction has the most empirical support in terms of reducing rates of suicide across diverse populations (Bryan & Rudd, 2018). Means restriction counseling involves assessing whether a patient has means that could be used in a suicide attempt or nonsuicidal self-injurious behavior, and then working with the patient and their supports to eliminate or limit access to these means until the patient’s safety is no longer at risk.

Most individuals who attempt suicide select their method only two hours prior to their attempt, and they tend to select whatever methods are most readily available. Therefore, eliminating access to as many lethal means as possible through means restriction counseling significantly reduces the likelihood a patient will complete suicide.

One in five clinicians does not ask patients about the availability of firearms, yet these weapons are lethal and account for over half of suicide deaths. Be sure to ask your patients about firearms as part of your assessment and keep trigger locks and cable locks in your office to provide patients if needed.

2. Create a Crisis Response Plan

Crisis response plans, also commonly known as safety plans, have been part of best-practice care for high acuity patients (patients that require a higher intensity of nursing care and monitoring) for decades. Recent research has shown that these plans are effective as a standalone intervention in reducing suicide attempts, suicidal ideation, and inpatient psychiatric hospital stays (Bryan et al, 2017).  

Common components of crisis response plans include:

  • Triggers for suicidal ideation and/or NSSI urges
  • Warning signs that suggest the crisis response plan needs to be implemented
  • Coping skills your patient can use without the assistance of others
  • Reasons for living
  • Natural supports who can be contacted for assistance
  • Professional sources of support

3. Encourage Self-Monitoring

Research suggests that self-monitoring of both physical and psychological conditions can facilitate positive behavioral changes. Additionally, when patients share self-monitoring data in sessions, it can help with a more efficient assessment of relevant behaviors and urges. 

Relevant targets for patients to self-monitor include suicide attempts, suicide planning behaviors, suicidal ideation, and nonsuicidal self-injurious behaviors and urges, as well as factors related to suicide risk. These can include things such as negative affect (e.g., sadness, guilt, anger), cognitive factors (e.g., hopelessness, perceived burdensomeness), and behavioral factors (e.g., substance use).

4. Utilize Chain Analyses

When planning effective interventions for patients experiencing suicidal ideation and/or nonsuicidal self-injurious behaviors, it is critical to understand the functions these thoughts and behaviors serve, as well as the common variables that precede and follow them. Chain analysis is a tool drawn from Dialectical Behavior Therapy (DBT) that can help clinicians explore relevant antecedents and consequences of urges and behaviors associated with suicide and NSSI.

5. Tailor Your Interventions

A completed chain analysis can then be used to inform the interventions targeting suicidal ideation and nonsuicidal self-injurious behaviors and urges. Many of the skills from DBT lend themselves well to targeting just that. In addition, these skills dovetail nicely with clinical strategies discussed in the literature on suicidal ideation and NSSI, like sleep hygiene, relaxation training, “reasons for living” lists, and activity planning.

There is a real possibility that suicidal ideation and nonsuicidal self-injurious behaviors will occur in an individual with an eating disorder. Fortunately, providers can play an essential role in the prevention and treatment of these behaviors. Educating yourself about suicide and nonsuicidal self-injurious behaviors is a critical component of providing the best possible care for your patients with eating disorders.

If you would like to learn more about eating disorders, check out the numerous other educational blogs on our website.


Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., Maney, E., & Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64-72.

Bryan, C. J., & Rudd, M. D. (2018). Brief cognitive-behavioral therapy for suicide prevention. Guilford Press.

About the Author

Alyssa Kalata is a Licensed Psychologist in the State of North Carolina. After receiving both her Master’s and Doctoral Degrees in Clinical Psychology from Western Michigan University in Kalamazoo, MI, and her Bachelor’s Degree in Psychology and Women’s Studies from the University of Michigan in Ann Arbor, MI, she completed her predoctoral internship at Duke University Medical Center with a focus on cognitive-behavioral therapy.

Alyssa has served in various roles during her professional career, including Clinical Supervisor, Research and Program Development Associate, Associate Clinical Director, Clinical Director, Clinical Trainer, and Clinical Training Coordinator working with patients diagnosed with primary eating disorders and primary substance use disorders in settings that provide services at a variety of levels of care.  Alyssa currently serves as the Clinical Training Manager for Accanto Health, with brands The Emily Program and Veritas Collaborative. 

Alyssa has a passion for the dissemination and implementation of empirically-supported treatments, particularly third-wave cognitive-behavioral therapies, with an emphasis on Dialectical Behavior Therapy (DBT). Her areas of expertise include the treatment of Borderline Personality Disorder, Eating Disorders, Substance Use Disorders, Mood Disorders, and Posttraumatic Stress Disorder and other trauma-related concerns and symptoms. Alyssa firmly believes that all individuals and their families and supports have the right to competent, compassionate care and her approach to treatment is one that balances understanding and validation with a focus on cultivating change.