„Will the patient sign a contract for safety reasons?“ asks a clinician or insurance agent on the other end of the line. „I don`t know,“ I reply. I often add, „And I don`t care.“ I then explain why I believe a „security contract“ in the emergency department is clinically unhealthy and can lead to disaster for some patients. Like patients who have no other place to go and who „know what to say“ to be admitted, patients who have already decided to cause serious harm to themselves or others also know „know what to say“ to get out of the emergency room. A patient`s emergency room safety contract, apparently taken literally, led to tragedy. I only know the story second-hand, but the source is reliable. I still had to figure out what Julia meant when she said, „I want to get out,“ the statement that took her to the emergency room and set the stage for our interview. At first, Julia said she didn`t know what those words meant. She admitted to being confused and overwhelmed by her feelings. I asked if, over the past month, as her depression worsened, she had ever thought about doing something specific that would threaten her life.
No, she said emphatically. She denied ever trying to hurt herself in the past. So what did Julia mean by wanting to „go out“? What did she want to „get out of“? Not life itself, apparently. A contract without damage is not a contract in the legally enforceable sense. If this client had really been injured, it would not be true that my agency would sue the client for breach of contract. There is no way to link anyone to this in any meaningful way. This usually involves an obligation on the part of the person not to hurt themselves without first contacting an agreed person to let them know how they are in crisis and plan to act according to their suicide plan. The designated person must also be familiar with the safety plan and accept their participation as a point of contact if they are in crisis or at risk of injury. I recently shared a research paper by Edwards and Sachmann1 on „suicide-free contracts“ with a colleague who is very familiar with suicide. This article concluded – like virtually all previous literature – that the use of suicide prevention contracts (CPS) remains a „questionable intervention in clinical practice.“ 1 Surprisingly, this study also found that a significant number of mental health professionals continue to rely on CCPs despite their „diverse potential for adverse outcomes.“ 1 My colleague expressed his astonishment that this practice is still used in psychiatry, given the many clear warnings in the literature about its abuse and unreliability.2 For this reason, harmless contracts have fallen out of favor over time. There is no evidence that they work.
They can even give you a false sense of security. They show that you saw the need to intervene to reduce the risk of suicide, and that you didn`t really do much to intervene. Legal experts have expressed concerns that this could make therapists legally liable if a client dies by suicide* and the family files a complaint or lawsuit. In all but a handful of overdose cases, I was able to work with the patient to understand what the overdose meant. Most patients reveal their intention quickly and willingly. „I wanted attention“ is the most common reason given. Others admit that they tried to punish a family member or loved one who they felt had harmed them. As a rule, someone who did not apply his will and was not willing to take an instrumental step to resolve the underlying conflict decided to dramatize the point. Countless mothers (and quite a few fathers) told me, weighing the situation, that their teenage son or daughter had just „had a pity party.“ What some patients try to say with pills, others express with superficial incisions, usually on the ventral wrist. A woman in her thirties was taken by her brother to the emergency room of another hospital.
Two facts dominated the case: 1) at home, the depressed woman had threatened to commit suicide, and 2) the brother`s gun had disappeared, and he was sure that the patient had taken her away. A social worker was called in to conduct an assessment and make a decision. The patient vehemently denied that she intended or intended to injure herself or to have taken her brother`s gun. She wanted to be released. An oral safety contract was concluded with the social worker. But apart from this speculation, it occurs to me that SPC could distract us from a more fundamental and paramount duty to our patients. I am talking about the duty to listen, rather than expecting a fragile and vulnerable patient to carry the burden of a „contract“ with multiple layers and vectors of strong emotional significance. The physician`s ethical principle of relieving suffering may include a wide range of ancillary actions. If a patient is struggling with emotional pain so intense that suicide is contemplated, relief of suffering at this acute stage can be done in two forms – 1) listening and 2) ensuring physical safety. SPC does not seem to do one or the other. My practice of entering the mind of the suicidal patient was to emphasize the importance of prioritizing the act of listening.
But of course, this was known a long time ago, and by men who were so much wiser than me: Moreover, there is still no reliable evidence that we can distinguish the fake from the true intention of suicide. 8 We do have some guidelines that point us toward mutilated mental illness.9 But the act of suicide is ultimately behaviour. The person who harasses auditory hallucinations, for example, may simply continue to pretend to hear voices more vehemently when doubts are expressed by clinicians. On the other hand, what is left for the person who claims to have suicidal intent (mutilated or genuine) when such claims are met with skepticism? Of course, it can be an attitude characterized by, „Well, so I`ll show you I`m serious.“ In other words, it should come as no surprise to any clinician when allegations of suicidal intent that are met with cynicism are then followed by deliberate action.