For instance, safety contracting may frequently be counterproductive in patients dealing with borderline or passive-aggressive pathology. With such patients, it is sometimes best to avoid the whole issue of safety contracting, because it may embroil the dyad in ineffective debates with statements such as, “I don’t know what to tell you. I guess I’m safe, but on the other hand, I can’t make any guarantees. Do you know anybody who can?”
If one uses safety contracting as a deterrent, it is critical to use it cautiously. It guarantees nothing and may yield a false sense of security. Moreover it should never be done before a sound suicide assessment has been completed. Generally speaking, I believe that safety contracting as a deterrent is viewed by most suicidologists as inferior to sound safety planning, although, to date, there is no research to prove the effectiveness of safety planning as a deterrent.
The power of the patient’s superego and the power of the therapeutic alliance may play significant roles in whether safety contracting, employed as a deterrent, may have use with a specific patient. I am convinced that in some patients, it may play a role in deterrence as with a patient in a long-standing therapeutic alliance, with minimal characterological pathology and a powerful superego. I have had several seasoned therapists approach me after workshops commenting that they have had patients clearly state that the safety contract functioned as a deterrent with one patient saying on a Monday after a particularly bad weekend, “The only reason I am alive today is our contract, for I couldn’t do that to you. I couldn’t break my word to you.”
But deterrence is not the only, and, in my opinion, is not the main reason to use safety contracting. The process of contracting for safety may be more frequently useful as an exquisitely sensitive assessment tool. In this capacity, it is selectively used in a small number of patients, who have no characterological pathology, in which the interviewer is leaning toward nonhospitalization after completing a suicide assessment but is bothered either by his or her intuition that the patient is more dangerous than they have stated or analytically feels something does “not add up here.” In such cases, rather than use safety planning, which has no interpersonal pressure to it, the clinician may opt to use safety contracting, in which the patient is “put on the spot” to make an agreement. Such an “interpersonal push” may prompt nonverbal leakage of hidden ambivalence or dangerous suicidal intent.
When used in this highly selective fashion, as the interviewer asks whether the patient can promise to contact the clinician or appropriate staff before acting on any suicidal ideation, the interviewer searches the patient’s face, body, and tone of voice for any signs of hesitancy, deceit, or ambivalence. Here is the proverbial moment of truth. Nonverbal leakage of suicidal desire or intent at this juncture can be, potentially, the only indicator of the patient’s true immediate risk.
Using the interpersonal process of safety contracting as an assessment tool, the clinician may completely change his mind about releasing a patient on the basis of a hesitancy to contract, an avoidance of eye contact, or other signs of deceit or ambivalence displayed while reluctantly agreeing to a safety contract. I vividly remember one patient, who adamantly did not want to be admitted to the hospital, whom I was about to discharge from my ED, but about whom I felt intuitively something was askew despite a careful suicide assessment. I decided to employ safety contracting as an assessment tool. When I asked whether he could promise to call us before ever acting on any suicidal ideation, he hesitated and briefly glanced down. When I pointed out that it looked hard for him to make the contract, he welled up and said, “I just want to die.” I commented, “You know, I think we should bring you into the hospital,” at which point he looked at me and said, with a pained foreboding “You probably should.” It was a chilling moment. He then agreed to be admitted.
The interviewer who notices such nonverbal clues of ambivalence can simply ask, “It looks as though this contract is hard for you to agree to. What’s going on in your mind?” The answers can be benign or alarming (as above) and the resulting piece of the puzzle—that could only be provided by the process of safety contracting—may lead to a change in disposition. This use of safety contracting as an assessment tool, based on nonverbal leakage of suicidal intent, unlike safety contracting as a deterrent (which probably has limited use in an ED) may be particularly useful in an ED. Thus safety contracting is complicated, and CASE-trained clinicians neither generically condemn nor condone its use but attempt to make a wise decision on the basis of the specific needs of the client and the clinical task at hand.
For a practical review of how to effectively use safety contracting, the reader is referred to “Safety Contracting: Pros, Cons, and Documentation Issues” where one will also find references to numerous articles on the subject.42 Remember that safety contracting is no guarantee of safety whatsoever.
Finally, it cannot be emphasized enough that continuing concerns about the safety of the patient or the validity of the patient’s self-report may require contacting collaborative sources.