I recently shared a research article on “no-suicide contracts” with a colleague who is very knowledgeable about suicide. That article concluded--as virtually all the previous literature had-that use of suicide prevention contracts (SPC) remains a questionable clinical practice intervention.
I recently shared a research article by Edwards and Sachmann1 on “no-suicide contracts” with a colleague who is very knowledgeable about suicide. That article concluded--as virtually all the previous literature had- -that use of suicide prevention contracts (SPC) remains a "questionable clinical practice intervention."1 Surprisingly, that study also found that a significant number of mental health professionals continue to rely on SPCs despite their “multifaceted potential for detrimental outcomes."1 My colleague expressed his astonishment that this practice was still being utilized in psychiatry, given the many clear warnings in the literature about their misuse and unreliability.2
My colleague’s response caused me to stop and reflect. Indeed--why do we continue to see this practice used?
The issue of the SPC and its substantial limitations has been well addressed for over a decade.3 Yet during malpractice case analyses, my colleagues and I continue to see reliance upon them, often to the great detriment of the patient and defendant psychiatrist. Not uncommonly, the depositions of clinicians being sued contain responses such as: “But, he contracted for safety…”
In an article reviewing the history and medico-legal concerns of contracting for safety, the authors found the practice was surprisingly misunderstood, yet relied upon in a variety of ill-advised ways.2 Some clinicians may use it as a slap-dash way of documenting a patient’s suicide risk. Some use it as a way of “managing” the patient’s suicide risk, failing to understand that it might help “assess” risk, but cannot be relied upon as an evidenced-based practice for preventing suicide.
There is general consensus in the professional literature that the SPC should not replace a comprehensive or systematic suicide risk assessment. Nevertheless, one still sees clinicians “contracting for safety” with patients despite the fact that: 1) the “contracts” do not protect against legal liability, 2) they are not considered “contracts” as understood by law, 3) they have no significant clinical research to support their use, and 4) there is an abundance of literature warning clinicians about the pitfalls of relying upon them. Table 1 lists some of the main reasons that the SPC is a very questionable practice.
Although SPC might create the (temporary) illusion of securing safety for a patient, they may often be more about securing peace of mind for the clinician. In effect, they are a contract for comfort--for the clinician. Thus--as is too often demonstrated--they may cause the clinician to overlook or underestimate the patient’s actual risk. The strength of such a “contract” will only be as good as the therapeutic alliance. Contracting for safety with a patient one has seen for only a relatively brief period drastically reduces its reliability in clinical practice, as well as its credibility in court. If a patient refuses to contract for safety, this may provide some worthwhile clinical data. But more commonly, patients will simply assent to the “contract,” which results in a highly questionable intervention.
SPCs also assume that a mentally impaired patient is capable of understanding, consenting, and participating. Should a patient with a serious mood or psychotic disorder commit suicide, rest assured that plaintiff’s counsel will point out the incongruous logic of asking a mentally confused and emotionally distraught patient to engage in a “contract.” The hard reality is that there are no short cuts, and no other way around performing a competent, timely clinical suicide risk assessment.
Finally, let us not turn away, but consider the grim, fearful circumstance in which a patient reaches a firm decision to commit suicide. Will such a patient be likely to inform a clinician of this decision? Perhaps an attempt to fathom the mind of a suicidal patient will bring us closer to an answer. This will require going beyond empathy, and using the forensic technique of putting ourselves fully inside the mind of the subject--in this case, the acutely suicidal patient. Ready? Here we go….
Think of it this way. . . Maybe you wanted it, maybe you didn’t. All that’s important now is that you’ve just been admitted to a psychiatric hospital. This means, simply put, things are not good. You’ve been thinking about suicide. The pain has been that bad. You’ve tolerated it for a long time, and you’re out of stamina. It’s a pivotal moment. You’ve been so indecisive--It’s time to make a decision for once...
Here’s what it’s all been heading towards ever since you started this painful, downward trip: Will you ever be equal to the deed? You hoped not, but one never knows how things will unfold. Hope has long dwindled, faded and then. . .extinguished like some distant sun on the edge of a never known galaxy.
But all this is past tense. Now--now you’re equal to the deed. You’re not cowering in front of death anymore. You see it, sense it. . . and you do not shrink. Your hospitalization has clarified your struggle from background noise into an intense, high definition message: All is so fragile now--things could go either way. 3 When you realize this, it has a strange effect on you. The uncertainty, the intensity--it gives you an adrenaline rush. You’ve felt so heavy and tired that this feels good by comparison. What will happen? The tension. The edginess.You fear your disquiet is so deeply rooted within you that no one can disentangle you from this affliction.
This doctor is afraid and you can so easily tell. He wants to prevent your escape5 from the pain because he’s afraid--for himself. Not you. Therefore, he merits no consideration. He’s not your ally, this doctor. He’s your adversary, because at this point his goal is the exact opposite of yours.6 He wants you stay in this place and continue along a path you have no interest in. So when he and the nurse ask you to sign a “contract” for safety, you sign it like the dozen or so other papers you’ve already signed. You sign it like an automaton. Perfunctory. Don’t create any waves, or it’ll give them reason to take away all your clothes, privacy and put you in a room with someone watching your every move.
Any idea what it takes, Nurse, to tighten the sheet around your neck and step out into infinity? It takes the worst pain of your life that will not quit. It takes seeing your brain as an offending organ, and the only thing you can do is throw it into a pool of oblivion. It takes living like this for an unbearable amount of time, and then. . .then it takes the right amount of antipathy towards life, and fearlessness--To walk up to death and take it by the hand. . .“Give it an apple. Walk up to its grave. Bite the apple first yourself.” 7
So why does the SPC persist despite all the countervailing data? I would submit that one reason is that the act of suicide is beyond our ability to predict. It is a human behavior with a low base rate, but with a high potential for human devastation. The aftermath is so horrendous, it is beyond words. Clinicians may clutch at any straw to avoid the emotional repercussions and painful countertransference associated with many suicidal patients. If only we could assuage our anxiety with the knowledge that the law does not require us to predict --only to adequately assess risk at the appropriate times--and then implement the appropriate treatment interventions.8,9
Moreover, there is not yet reliable evidence that we can distinguish feigned from genuine suicidal intent. 8 We do indeed have some guide posts to point us in the direction of malingered mental illness.9 Yet the act of suicide is, in the end, a behavior.The individual who malingers auditory hallucinations, for example, may simply continue to claim hearing voices more vehemently when doubt is expressed by clinicians. In contrast, what does the individual who claims suicidal intent (either malingered or genuine) have left when such claims are met with skepticism? Naturally, it may be an attitude characterized by: “Well then, I’ll show you I mean business.” In other words, it should surprise no clinician when claims of suicidal intent, met with cynicism, are then followed by a deliberate act.
But setting this speculation aside, it occurs to me that SPC may be distracting us from a more basic, overriding duty to our patients. I speak here of the duty to listen, as opposed to expecting a fragile, vulnerable patient to bear the burden of a “contract” with multiple layers and vectors of powerful emotional meaning. The physician’s ethical tenet of alleviating suffering may encompass a broad array of helping acts. When a patient is struggling with emotional pain so severe that suicide is being considered, alleviation of suffering, in this acute stage, may come in two forms – 1) listening, and 2) ensuring physical safety. The SPC would appear to do neither. My exercise of stepping inside the mind of the suicidal patient was aimed stressing the importance of giving primacy to the act of listening. But of course, this was known very long ago, and by men so much wiser than me:
For who listens to us in all the world, whether
He be friend or teacher, brother or servant?
Does he listen, our advocate, or our husbands or wives,
Those who are dearest to us?
Do the stars listen, when we turn despairingly away
From men, or great winds, or the sea or
The mountains? To whom can any man say – Here I am!
Behold me in my nakedness, my wounds, my secret
Grief, my despair, my betrayal, my pain,
My tongue which cannot express my sorrow, my
Terror, my abandonment.
Listen to me for a day – an hour – a moment!
Lest I expire in my terrible wilderness, my
Lonely silence. O God, is there no one to listen?
Patient determined to commit suicide views staff as adversary, not ally
1. Edwards SJ, Sachmann MD. No-suicide contracts,no-suicide agreements, and no-suicide assurances: a study of theirnature, utilization, perceived effectiveness, and potential to cause harm. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2010;31(6):290-302.
2. Garvey K, Penn J, Campbell A, et al. Contracting for safety with patients: clinical practice and forensic implications. J Am Acad Psychiatry Law. 2009;37:363-370.
3. Simon R. The suicide prevention contract: clinical, legal, and risk management issues. J Am Acad Psychiatry Law. 1999;27(3):445-450.
4. Seiden R. Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide Life Threat Behav. 1978;8(4):203-216.
5. Baumeister R. Suicide as escape from self. Psychological Review. 1990;97(1):90-113.
6. Resnick P. Recognizing that the suicidal patient views you as an "Adversary." Current Psychiatry. 2002;1(8).
7. Excerpted from: Poem on Death by Inger Christensen.
8. Freedenthal S. Challenges in assessing intent to die: can suicide attempters be trusted? Journal of Death and Dying. 2007; 55(1):57-70.
9. Rogers R. Clinical Assessment of Malingering and Deception, 3rd Edition. New York, NY: The Guilford Press, 2008.