Debate over “No Suicide Contracts” presumes Patients are All Alike

An article entitled No Suicide Contracts: Can They Work by Caroline Roberts M.D. came out in the August 2020 issue of Clinical Psychiatric News. No suicide contracts (NSC’s) had been given for years by therapists and psychiatrists to potentially suicidal patients. The contract essentially gets the patient to sign off on a statement that they will not kill themselves. Alternatively, the patient commits to calling someone if they think they might make an attempt. Some NSC’s ask them to call a suicide hot line, while others say to call the therapist.

 

For quite some time now, however, use of NSC’s has been discouraged in the literature because they may give therapists a false sense of security. There is no clear-cut evidence that they are “effective.” In some populations, such as borderline personality disorder (BPD) where the patient may want to invalidate the therapist, they might even backfire. Or patients may not keep their word because they know the therapist might commit them to a mental hospital. They might not want to go there.

 

Dr. Roberts (“She helps you to understand and does everything she can” ~ say the Beatles) makes the obvious point in her article that the answer to the question of whether NSC’s can work “is conditional on the unique combination of patient, clinician, and therapeutic relationship.” And, I might add, the unique family dynamics and history of prior treatment that each patient brings to therapy. How could anyone think that the question of whether any intervention either will or will not work does not depend on everything that has happened before, during, and after the signing of the contract – both in the patients’ lives and in their relationship with the therapist?

 

This is yet another example of the ecological fallacy, in which an entire group of people is characterized just by its average member. It’s like the old joke about a drowning victim who couldn’t possibly have died in a certain lake because its average depth is only three feet!

 

Of course, no intervention is going to be effective 100% of the time in anyone. For one thing, new things can happen to a patient in between therapy sessions. Family fights can break out or people can be dumped by lovers. A loved one might even pass away.

 

Telling a patient to call a hot line will generally be less effective than if the patient can talk to the therapist personally. The patient may think (and I agree) that therapists should care enough to be available during emergencies, and to have someone who can substitute for them if they are not available. Therapists should also know how to empathically get patients off the phone in non-emergency situations.

With patients with BPD, therapists will most likely have better results with an NSC if they have validated their patients without having fed into their false selves.

The therapist can ask patients if they are afraid they might be committed, and let them know that commitment will only be used as a last resort to save the patient’s life, and that the therapist realizes that patients can feel even worse when thrown into a mental hospital.

 

Simple answers to complex questions are usually simple minded, as they are here, and are only employed by simpletons. 

Book Review: Saving Ourselves From Suicide: Before and After by Linda Pacha

 

This book describes ways to handle your emotions and responses if you lose someone close to you to suicide. The author herself lost her son that way a few years ago. He was away at college for the first time. He had been diagnosed by one of two therapists as having Asberger’s Disease, a mild variation of autism, and was also experiencing confusion about his sexuality. He was having trouble relating to his classmates and was the subject of a lot of gossip and innuendo. He told his mother he felt depressed but never at any point in time mentioned that he was thinking that he might want to kill himself. The story the author tells in the beginning of the book about what happened with her son during this period is both gripping and highly disturbing. The author is an excellent writer.

 

The advice she give to parents and other survivors throughout the book is spot on. She talks about all the second guessing survivors subject themselves to, all the what-ifs and if-onlys, and the difficulties in interactions with friends, family, and acquaintances. What if you are being judged?

 

She relates her experiences and gives advice on issues such as how to handle grief during the first and second years after the death.  How does one handle anniversary reactions or one’s shattered religious faith?

 

She then goes on to her views about how to spot warning signs that someone you love is heading down the path of suicide, and how people in general and parents in particular can advocate for mental health and decreasing all of the pressures on today’s adolescents.  And then she goes on to the general subject of helping others who have gone through what she did.

 

Since she is not a mental health professional herself, she wisely avoids discussing suicides that result from adverse childhood experiences like sexual or physical abuse by parents, domestic violence, chaotic parental relationships with substance abuse and/or frequent affairs, parental alienation in divorce cases, double messages in the family, and the like. The book is not at all meant for those types of parents, whose problems far exceed the loss of a loved one, as bad as that still can be for them.

 

Another point that I like to make is that people who come from an abusive or chaotic environments are way more likely to become bullies or to bully others themselves, which means that the idea that bullying is the main cause of suicide is somewhat of a red herring.  As is the idea about suicide being caused by watching TV shows like 13 Reasons Why. Watching that could conceivable affect the timing of an attempt, but is hardly the actual cause. People are not that fragile.

 

I was happy to see that she wrote about the problems created by helicopter parenting, although she doesn’t use that term. A lot of parents these days are being absurdly over-protective to the point where kids today often feel fragile and incompetent , as well as a big burden on their parents. In response, they may in some cases start to think the parents would be a whole lot better off without them. This has gotten out of hand on college campuses with all the nonsense about microaggressions and “safe spaces” and viewing other people’s opinions as traumatizing.

 

This is in general an excellent book and well worth reading.

New Podcast Interview about My Psychotherapy Paradigm

I am interviewed by Serge Prengel, LMHC about the history of and the philosophy behind my ideas about psychotherapy with patients who have personality disorders: https://relationalimplicit.com/allen-2/