from Psychotherapy Review, 1993

I recently came across a little article in a Risk Management publication on a subject that has interested me for some time.  The article is by Doug Jacobs, who is a “big macher” (French for “expert”) in depression and suicide, so it lends authenticity to my own opinions, which I am prompted to share with you.

THE BOTTOM LINE: I think that “contracting for safety” is not a good thing to do because:

1. It offers no guarantee that the patient will not attempt suicide, and gives a false sense of security to the provider.  There is no evidence to show that contracting for safety prevents suicide or suicide attempts.

2. It offers no real medicolegal protection to the provider in the event that the patient “breaks the contract.”

3. It invites a dishonest relationship between the parties.

4. It promotes regressive acting out on the part of borderline patients.

5. It reinforces the superior-subordinate relationship between therapist and patient, saying, in essence, “Promise me you won’t kill yourself,” or “Do it for me,”  as though a mother were talking to a 5- year old child.  It reduces the autonomy and promotes the dependency of the patient.

I think that many times we contract for safety  for our own benefit, and not the patient’s.  Many times we are worried about someone’s suicide potential, and, when we are not certain, we seek to reassure ourselves and to reduce our own anxiety by asking the patient to promise not to kill him/herself.  We call this contracting for safety.  Should the patient attempt suicide despite the contract, we try to reduce our sense of guilt, saying, “We did discuss suicide, and she promised me she wouldn’t do it.”

In this age of liability and malpractice suits, we seek protection for ourselves.  We think that if we write “Contracted for safety” in the chart, we are protected.  In fact, the question that a judge, a jury, a supervisor or peers will decide is not whether we contracted for safety, but whether we recognized the possibility of suicide, whether the patient was competent to assume responsibility for his/her own actions, and whether the subject was addressed and alternatives discussed.

It is not easy to assess suicide potential.  There is no pat formula or rating scale.  All kinds of risk factors enter into the hopper: family history of suicide, substance abuse, age, sex, gun availability, capacity to form relationships, history of prior attempts, medical illness, recent loss, future-orientation, presence of psychosis, major depression, organic impairment.  It is our job as clinicians to make the best assessment we can, drawing upon clinical experience and, when necessary, upon the help and opinion of colleagues and supervisors.

It is our job to establish the best therapeutic alliance we can with the patient.  We must address the question of suicide directly and honestly.  We must explore alternatives with the patient.  When we are done, we make the best decision and intervention that we can.

If we conclude that the patient is capable of responsibility for his/her own actions, and can make a therapeutic alliance, we make arrangements for follow-up and future treatment.

If we conclude that the patient is incapable of responsibility for his/her own actions, despite what he/she promises, and we confirm the presence of major psychiatric disorder, we commit that patient, or restrict that patient to the unit, or put him/her under constant observation, or medicate him/her, etc.

If we are not sure, we should confer with a colleague or supervisor, and share the load.

But to contract for safety, to extract a promise that the patient may or may not keep, does no one any good, and, in fact, can do a good deal of harm (see above).

With regard to the borderline acting-out patient, with whom so many of these false and dishonest contracts are made, I think that a cornerstone of the treatment of the borderline is to promote his/her autonomy, and to insist that he/she is responsible for his/her own actions.  Contracting for safety says to the borderline: “Promise me you won’t kill yourself, for I am responsible for what you do, and you are not.”  This is clinically contraindicated.

Finally, with regard to medicolegal protection, the most important thing we can do is to document our assessment, as well the rationale for our therapeutic plan.  It is perfectly reasonable to write:

Patient hints at vague suicidal ideation, will not discuss whether or not she has a plan, constantly checks my reaction out of the corner of her eye.  She is not psychotic, nor is she clinically depressed.  She is regressed, has a long history of regressive suicide attempts and other forms of acting out, and a well-documented history of borderline personality disorder.  While the possibility of suicide is always present for her, I believe that she is competent to take responsibility for her own actions.  She seems to be seeking hospitalization, but multiple hospitalizations have done nothing to stabilize or improve her condition, and she has even attempted suicide in the hospital.  Hospitalizing her or contracting for safety will only promote regression, and reinforce this maladaptive form of acting out. I believe that firm limit setting, preventing regression, reality testing, and insistence that she take responsibility for her own behavior is the proper course of clinical action.  She has an appointment Thursday in the outpatient clinic, and I have urged that she keep it.

Such a note will protect you much more than a note that says, “Able to contract for safety.”  If you have discussed the case with a colleague or supervisor, you will be able to sleep at night, provided, of course, that the patient does not wake you.