Today we’re going to hear from a parent whose daughter has anorexia and has threatened suicide during meals. Obviously, this is a tough topic, but it’s not uncommon so I’m going to give you a practical, step-by-step approach that I’ve seen work well.
The letter
Dear Ginny,
My daughter is 12 and we’re doing FBT for anorexia. It’s been really, really hard. But we’ve made progress and the weight has been going back on. But now I’m stuck.
She’s started threatening suicide when I prompt her to eat. It usually happens towards the end of the meal when she’s full and uncomfortable. Also, it’s only happening at the table. Our FBT therapist says it’s a diversion tactic by the eating disorder and I need to just keep reassuring and prompting my daughter to eat but that I should call 988 if I’m worried she intends to do it.
That doesn’t feel like enough to me. I’m having a really hard time dealing with this. Can you give me any advice about what to do?
Signed, Kelly
My response
Hi Kelly, I’m so sorry this is happening. Your therapist is absolutely right that you want to keep moving forward with the meal and also, if you’re worried about your child you should not hesitate to call 988.
But what I’d like to give you is a few more options for preparing for threats and responding when they happen to help you get unstuck and unfrozen. This method should help you prevent and respond to threats during meals.
Since you’re working with a therapist, I suggest you think through what I’m about to say and then talk to her and see if she agrees with this course of action. The last thing I want to do is interfere with a treatment program being administered by your therapist who knows both of you and is therefore able to help.
⭐ Get ready for recovery and find out how you can prepare yourself for maximum success.
⭐ Find out the essential steps and family rules you need to have in place for recovery.
⭐ Make your home recovery-ready with six simple steps that anyone can do.
Understand why
Let’s start with understanding why suicidal threats may show up at the table when your child with anorexia is being asked to eat.
Basically, someone with anorexia is overtaken by powerful psychological and physiological forces to resist and avoid eating. Being faced with a meal typically causes extreme anxiety. And like all people, anxiety will trigger the fight, flight, or freeze nervous system response.
You’ve probably seen this in many different variations throughout treatment.
Fight might be arguing and negotiating about what’s on her plate.
Flight might be running away from the table.
Freeze might be slumping down and refusing to look at the food or pick up her fork.
All of these responses are natural and understandable. Now suicidal threats could fall into any one of these three anxiety responses.
If it’s a fight response suicide may be a powerful way to argue and negotiate.
If it’s flight, your child is trying to escape the food and pressure to eat, so they want to disappear through suicide.
If it’s freeze, your child might be so flooded by their thoughts and feelings about eating that the only option they can think of is dying.
Obviously there are a lot of ways to look at this. But the main thing is that thoughts of suicide are not uncommon for someone who has anorexia and is being asked to eat, and there are good reasons for that.
Talk about suicide
Most parents are understandably worried about talking about suicide. It’s unimaginable and terrible, and most of us don’t want to think about it, let alone talk about it. But it is very important that you learn how to talk about suicide.
The American Foundation for Suicide Prevention says that asking your child directly about suicide will not increase their risk, or plant the idea. It will create an opportunity to offer support, and let them know you care enough to have the conversation.
So what to say? First, let her know that you are grateful that she has shared her suicidal feelings with you and that you are here to listen and help. Use active listening skills and try to be curious and open to what she says.
If it feels right, let her know that suicidal feelings are very scary, but they are also follow a predictable pattern. They escalate up to a peak, then dissolve naturally. The goal is to get through the feelings without acting on them.
Tell her that you understand these feelings are very hard to feel and that you will take care of her and keep her safe.
The most important thing about this conversation is to stay as calm and regulated as possible so she can feel your love, strength, and compassion.
⭐ Get ready for recovery and find out how you can prepare yourself for maximum success.
⭐ Find out the essential steps and family rules you need to have in place for recovery.
⭐ Make your home recovery-ready with six simple steps that anyone can do.
Making an announcement
Once you’ve had that conversation, you can make a formal announcement about how you will respond to any future suicide talk during meals.
I suggest you write your child a letter. In this letter, I’d like you to start by saying how proud you are of her for feeling all her difficult feelings when eating. That you understand how hard it is to eat when you have anorexia, and that you admire the effort she is putting into every meal. Next, say something like this:
I’m really glad you let me know that you’re having suicidal thoughts during meals. It’s not easy to say what you’re feeling, and I want us to keep the lines of communication open. The truth is that in the past I didn’t know how to respond. But I’ve done some research and now I know what I need to do.
From now on, if you talk about suicide during a meal I will thank you for telling me and ask you once whether you plan to end your life. If you tell me “no,” then we will continue with the meal, and we’ll circle back to talk about your suicidal feelings after we’re finished eating. However, if you don’t answer or say “yes,” we will end the meal and immediately go to the emergency room. Your life is precious to me, and I will take action to protect you.
Then tell her you love and support her. Let her know that she’s not in trouble and that this is not a punishment.
Here’s a draft letter that you can use.
Now print two copies, and hand her one copy while you read the other one out loud to her. That’s right. You should read the letter out loud to her. I know this may seem overly-formal, but you want to show how serious this is.
Simply read the letter out loud in a calm but firm voice, tell her how much you love her, and leave the copy with her. Don’t be overly concerned with what she does while you read it. You don’t need to force her to listen, just stay calm and confident.
At the next meal
OK, so you’ve made your announcement, and now you’re heading into your next meal. I’d like you to take a few minutes to ground yourself before the meal. It is vitally important that you go into the meal confident that you can handle whatever happens. I promise you, you can!
Follow the steps you’ve been taking to serve the meal. Don’t make any changes.
Now you’re sitting at the table with her and she’s eating. This can go several ways.
First, she may not threaten suicide. Sometimes talking about suicide and delivering the announcement will end mid-meal suicide talk.
If she does threaten suicide, say “I’m glad you’re telling me that you’re having these feelings. Those are hard feelings, and I’m sorry. Can you please tell me if you have a plan to end your life right now?”
If she says, no, thank her for telling you about the feeling, tell her how much you love her and that you will talk more about the feeling later. Then move on with the meal.
If she cannot answer or says yes, then kindly and compassionately end the meal and head to the emergency room.
I know going to the emergency room is unpleasant and you may not be sure she really needs to go. But taking her to the emergency room shows her how serious you are about the risk of suicide, even if you are not 100% sure she would follow through.
⭐ Get ready for recovery and find out how you can prepare yourself for maximum success.
⭐ Find out the essential steps and family rules you need to have in place for recovery.
⭐ Make your home recovery-ready with six simple steps that anyone can do.
If you go to the ER
If you determine that you need to take your daughter to the emergency room, then speak calmly and confidently to her on the way. Tell her how much you love her and are determined to keep her safe. Thank her for telling you about her feelings and let her know that you are here for her.
During the ride she may say she’s not suicidal and ask you to take her home. It may be best to follow through with the plan anyway and go to the emergency room. The best alternative to going to the emergency room in this situation is to pull over and call 988 or ask your child to call 988 and see what they recommend. What you wouldn’t want to do is just turn around and go home without some form of formal, professional advice.
If you get into the emergency room even if your daughter says she is no longer suicidal, they will still walk her through the suicide protocol and assess whether she is safe to go home. This is something they should be equipped to handle. And you should definitely not feel guilty or embarrassed for bringing your child to the emergency room when there’s a threat of suicide.
Going to the emergency room is unpleasant, but necessary. In your letter to her you said you would take threats of suicide seriously, and that’s what you did. Following through is a big part of the value of this intervention.
Moving forward
Whatever happens, even if she stops talking about suicide during meals, please keep talking about suicide. Check in with her outside of meal times to find out if she still has suicidal feelings, thank her for telling you when she does, and offer to help her when she’s having these hard feelings.
Kelly, I know this is a tough spot to be in.
Please remember that you can always call the national suicide hotline at 988 and get real-time advice from a trained professional. The hotline is designed to help people like you figure out what to do next, so if in doubt, call!
I wish you all the best as you face this challenge.
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