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.