Seeing as I have been suicidal the past few weeks, sometimes intensely, other times not so much, I thought I would talk about the dreaded “no suicide contract”. In an article by Rudd, Mandrusiak, and Joiner (2008), the authors describe that there is no empirical data that proves a contract is a deterrent to suicide anymore than say pinky swearing (my words not the authors). In these times where suicide rates are going up rather than down, it is important to have something in place so that the therapist and client feels comfortable sharing the suicidal feelings without always resorting to hospitalization. The authors in this article promote a “commitment to living statement” as way to facilitate 1) identifying roles, obligations, and expectations of both clinician and client, 2) communicate openly and honestly about all aspects of treatment including talk of suicide, and 3) identify emergency services usage when client cannot contain the agreement.
This agreement seems to me as a good way to start any conversation of suicide but it also feels like it is an informal consent contract. It doesn’t really focus on a suicidal behavior tracking plan like the Suicide Status Form. All it does is explicitly states that the client make a commitment to living.
I was reading this because I thought it was a unique contract but now I am thinking that it is not. It does however, give the clinician and client a time focused treatment plan that I think all therapists should have with their clients so that if something is not working, it can be changed so it does work. In my experience, I think that this would be helpful for my therapy but I think it might be too late for that as we are no longer seeing one another face to face and this contract requires a handwritten statement to be made.
My therapist and I have reached another impasse and I think sometimes that having a break is beneficial. It gives me time to think things over. I also think that if I had the inclination, I would bring this article up again with her and see what she thinks of it to help my suicidal tendencies. But I am not sure about the whole commitment to living aspect of it. It does seem to me that something needs to give and she needs a piece of mind that doesn’t include me telling her I want to kill myself every week. The biggest thing on the commitment statement is that it allows for goals to be set. In my twelve or so years of being with the same therapist, I don’t think we ever have set one goal in treatment. Usually I was the one to come up with a treatment plan on how I wanted to be treated. That was fine until I ran out of gas and ideas. But what would setting a goal after all this time be like? I don’t know as I have not really thought about it. My therapist doesn’t give me homework, other than possibly blogging about something she has in mind for me to work on. We generally have an unspoken agreement that I will call her should I think about acting on my thoughts to harm myself. The most I have done is text her, a lot, to let her know I am having a hard time with my thoughts. Usually this happens during the long weekend when either she is away or when we have a long few days between sessions due to the weekend or holidays. I try not to text her so much but she seems to like me keeping her in the loop so I do it to sort of please her. Plus it tells her that I am still alive so that eases her anxiety a little.
An example of the Commitment to Treatment Statement is the following:
I, ________, agree to make a commitment to the treatment process. I understand that this means that I have agreed to be actively involved in all aspects of treatment including:
1) Attending sessions (or letting my therapist know when I can’t make it
2) Setting goals
3) Voicing my opinions, thoughts, and feelings honestly and openly with my therapist, whether positive or negative but most importantly my negative feelings
4) Being actively involved during sessions
5) Completing homework assignments
6) Taking medications as prescribed
7) Experimenting with new behaviors and new ways of doing things
8) Implementing my crisis response plan when needed
I also understand and acknowledge that, to a large degree, a successful treatment outcome depends on the amount of energy and effort I make. If I feel like treatment is not working, I agree to discuss this with my therapist and attempt to come to a common understanding as to what the problems are and identify potential solutions. In short, I agree to make a commitment to living. This will apply for the next ____ months at which time it will be reviewed and modified.
To me, as I have said before, this looks more like a basic agreement contract to therapy than it does for specifically suicidal thinking/behavior. The reason I bring it up is because most clinical therapist do not have such specific language in their agreement and I think it is important to work together in treatment. A client should always have a say in treatment, no matter if it is in psychotherapy or medicine. With a little modification of the wording, this statement can be used in any clinical scenario. It is basic and to the point. Clients should be active in the care but sometimes that is just not possible. I mean if you have a throat infection, you are not going to argue with your doctor about treatment. You will want the antibiotics so that the infection doesn’t spread and you get sicker (if it is a bacterial infection to begin with). But it gets trickier with something complex as say diabetes. This blog doesn’t deal with that so I won’t say anything further about it. Just know that you should always advocate for your say in treatment and ask questions about why you are being placed on medication or physical therapy or whatever your doctor prescribes.
Basically, I have to agree that this commitment to treatment statement (CTS) is better than a “no suicide” contract because it (CTS) allows open discussion and collaboration of treatment whereas the no suicide contract will just state that the client will not kill him/herself.
The second part of the CTS agreement is the Crisis response plan (CRP). It states:
When thinking about suicide, I agree to do the following:
Step 1: Try to identify my thoughts and specifically what’s upsetting me
Step 2: Write out and review more reasonable responses to my suicidal thoughts
Step 3: Do things that help you feel better for at least 30 mins (examples can include, trying to sleep, play internet games, brush hair 100 times, write in a journal, listen to music, etc)
Step 4: Repeat all of the above
Step 5: if thoughts continue, get specific and I find myself preparing to do something, I will call XXX @ 555-555-5555 or suicide hotline
Step 6: if I cannot reach above I will call my therapist or psychiatrist
Step 7: if I am still feeling suicidal and I don’t feel like I can control my behavior, I go to the ER or call 911 (or whatever the local emergency line is for your country).
Either plan is effective even though neither have been empirically tested. The CRP I have used in my treatment and I have found it useful. During one of my recent hospital stays, I actually gave out the CRP to other patients hoping they would benefit from its usefulness.