Thank you to everyone who responded to our September Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
September Quandary: I’m a new clinician working with a client who’s expressed some suicidality at times. I don’t think he needs to be hospitalized, but I’m worried about him. I think it might be a good idea to have him sign a no-suicide contract, but I’ve heard mixed things about them. What should I do?
1) Be Willing to Change Direction
When I was starting out in the field, I worked at a practice where my supervisor directed us to use no-suicide contracts. At the time, I had no knowledge of their ineffectiveness and problematic nature. After I left that practice, I became more aware that other clinicians not only didn’t use no-suicide contracts, but had strong professional objections to them. I haven’t used them since leaving that practice.
As an alternative, I develop safety plans with my suicidal clients, and I make them as collaborative as possible. The safety plan isn’t a contract, and it’s written so the client isn’t left having to remember it and can reference it as a guide. It tends to include several things: a) specific people, reasons, or things that are worth living for, b) specific warnings signs that the client may be vulnerable to acting on suicidal or self-harming thoughts, c) specific people they can reach out to, d) specific steps they can take to cope and/or distract themselves when they feel hopeless or unsafe, e) contact information for Suicide Hotlines and on-call clinicians, and addresses for 24-hour urgent care locations.
After we’ve drawn up the safety plan, I encourage the client to allow us to share this information and plan with another person before the session ends. Unlike a contract, all these steps are designed to give them hope, communicate that others care, and give them specific, alternative actions they can take instead of hurting themselves.
Jonathan Hetterly, MA, LPC
2) Welcome All Parts
Before being trained in Internal Family Systems (IFS), I was anxious about working with suicidal clients. Having a safety contract calmed my anxious parts, but I worried the client would just stop talking about his or her suicidal thoughts for fear of the consequences. It seemed like a lot to ask of someone so vulnerable.
IFS views suicidal ideation as one of many internal parts, including some that want to live. The part that signs a safety contract may be a compliant part, but even noncompliant parts have a positive intention. Suicidal parts are desperately trying to convey their deep pain and longing for connection or, perhaps, the pain of a younger part they may be protecting. I’ve seen from experience that they often believe being extreme is the only way to get our attention.
I welcome those suicidal parts in my work as having valuable information, and I devote time to getting to know them. Why do they do what they do? What are they afraid could happen if they don’t do these things? Just as a child in a family system who acts out can bring honesty and wisdom, so too do these parts. Feeling seen, heard, understood, and valued calms these frightened ones.
More often than not, I find that suicidal parts have been exiled, muscled down, or just plain ignored. Facilitating a trusting relationship between the client’s Self—a healing resource—and a suicidal part is key. Once this is established, the next steps—witnessing, unburdening, and integrating—can take place. Using this framework, I’ve seen how quickly our clients’ systems can shift.
Tish Miller, LCSW
3) Focus on the Therapeutic Alliance
If I was this clinician, I’d recommend the client keep a therapeutic diary, rather than sign a no-suicide contract, with notes and tips we learn in-session that he can read each day. The therapeutic relationship is more important than any contract. It’s collaboration that lends hope and builds empowerment. We can help this along by doing risk assessments at the beginning of sessions, interoceptive exposure, mindfulness exercises, or flash-forward imagery exercises.
Once we help our clients develop resilience, they move away from negative automatic behaviors and low self-esteem. It supports them in moving away from the belief that the only way to resolve a problem is to escape through suicide. Regardless, we need to accept, with compassion, that suicidal clients sometimes feel as if this is their only escape.
Gillian Solomon, HCPC UK accredited BABCP member and CBTSA member
4) Create a Safety Plan
In my work as codirector of the Suicide and Violence Prevention Office at Nova Southeastern University and author of numerous books on suicide prevention, I’ve heard numerous criticisms of no-suicide contracts. Even though best practices have replaced them with safety plans, there are still clinics and mental health professionals that continue to use them.
The major criticism of a no-suicide contract is that it focuses on what the client is not to do, rather than emphasizing safety measures the client can take when feeling suicidal. Additionally, the client might feel coerced into signing the contract. It’s also worth noting that no-suicide contracts don’t necessarily protect therapists from potential liability should a client suicide occur.
A safety plan needs to be developed jointly with clients. When doing this, the therapist should sit next to the client to signify their partnership and collaboration. There are two primary components to a safety plan. The first emphasizes how clients can support themselves internally if they’re having suicidal thoughts. This includes a discussion of calming practices, like deep breathing, relaxation, and positive imagery.
The second key component is for clients to identify external supports. This could include family, friends, mental health professionals, and national prevention resources, such as the National Hotline and crisis text line.
There are samples of safety plans available from SAMHSA and the Suicide Prevention Resource Center that focus on helping clients manage a suicidal crisis. It’s my view these plans should be signed by both therapist and client, and updated periodically in subsequent sessions.
Scott Poland, PhD, EdD
Fort Lauderdale, FL
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
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