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Clinician's Digest - Page 3

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Responding to Suicidal Clients

When a therapist suspects a client is contemplating suicide, one of the commonest interventions is a procedure called suicide prevention contracting (SPC), either a formally written contract or a firm verbal assurance or agreement. Although the research has been clear for years that SPC isn’t very effective at preventing suicides, many therapists figure it might work, and, if worst comes to worst, SPC could afford some legal protection. But in the November 2010 Crisis: The Journal of Crisis Intervention and Suicide Prevention, social worker Stephen Edwards points out that these are both serious miscalculations. Edwards cites studies showing that insisting on SPC may actually increase the likelihood of suicide, and, given the research demonstrating its ineffectiveness, SPC won’t prove due diligence or clinical competence either.

Therapists, says Edwards, coauthor with Christopher Goj of the forthcoming book Suicide Prevention Contracting, need to know about a “deadly dangerous paradox” of SPC, especially because a survey of 420 therapists conducted by Edwards and social worker Mark Sachmann found that about 80 percent of them believed SPC causes no harm. Although therapists believe that SPC communicates their concern and compassion, research finds that many clients, especially those with histories of suicide attempts, see SPC as an attempt by therapists to protect themselves. Suicidal clients who feel that a therapist’s primary concern is self-protection may mask their feelings of rage, despair, or abandonment and agree to SPC, leaving the therapist feeling safer, but in no way helping to protect the potentially suicidal client.

So what should therapists do when a client appears to be suicidal? Noting that, “The strength of any suicide contract rests only on the strength of the therapy relationship,” Vancouver, B.C., psychologist Michael Mandrusiak advocates using a treatment agreement instead of SPC in the February 2006 Journal of Clinical Psychology. “From suicidal clients’ perspectives,” says Mandrusiak, “suicide isn’t their problem, it’s their solution.” Insisting on SPC backs them into a corner and is as likely to shut down treatment as enable it.

Instead, Mandrusiak says, therapists should try to get clients’ agreement to give treatment a chance, implicitly or explicitly leaving the suicide option on the table. Talking about a treatment agreement serves as a preliminary assessment of the seriousness of the suicidal intent: clients who won’t agree at least to discuss a treatment agreement are likely at higher risk. That’s the kind of information you won’t get out of SPC.

Part of the treatment agreement should include a safety plan. Clients who participate in drawing up their own plans are already engaging in treatment. Mandrusiak advises therapists to enlist clients’ creativity. Which friends and family members can clients call on when they’re desperate? How will they discuss with them their inclusion in the safety plan?

As the dialogue proceeds using this approach, the therapy relationship is likelier to open up, replacing the negative energy of don’ts with collaboration and hope. “Persuading clients to promise not to kill themselves makes them passive and puts clinicians in the driver’s seat,” notes Mandrusiak. “Effective change occurs when clients are active participants.”

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