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noname223

Angelic
Aug 18, 2020
4,676
I want to keep posting my threads. But currently I am exhausted and lazy at the same time. I hope the copyright sharks won't demonitize this thread. (little side joke). I mean I do the science community a favor with this thread. I am scared to get in trouble for copyright stuff but that is extremely unlikely. It is probably more likely to get swatted for posting threads on here. Lol.

Here is a good German science article on the topic. I barely have knowledge on it so I guess it will be better if I just use a translator for interesting parts.
I am not sure whether I signed such a contract with my last therapists. But I did when I was in clinic. They say in the study that there is scientifical evidence that anti-suicide contracts contribute to preventing suicide (as long as they are in therapy (?)) Personally yes I felt bad for my therapists. But this contract was not the reason. Maybe I underestimate the impact but while I was severely acute suicidal I thought about the impact on friends way more than about the impact on therapists and even way way less about this sheet of paper. But whatever it is a long time ago I signed one. Maybe my memories are distorted. What were your experiences? I hope they are rather thankful for this unique opportunity to get feedback from suicidal people for their paper. For ethical considerations they probably would never sign up as member. But they are hypocritical enough to use this forum still for research. To be honest I don't really care. The science community is way more nuanced on suicide forums than the fearmongering media.

It is open access so I hope they won't be too mad.


Warning this thread might not be enough pro-choice for some people. Though this discussion still fits the best in this sub-forum.

Summary
The treatment of suicidal patients bears a component that is not subject to every psychotherapy: the threat of the patient's life. Accompanied by fear of the practitioner for the patient or legal consequences. Due to this, non-suicide-contracts (NSC) are often used. The intention of such an intervention can be seen in the maintenance of the therapeutic process and in the protection of life and limb of the patient. The initial usage of NSC as well as it's prevalence are shown. Furthermore, selected studies are presented, factors are mapped out (main effect, side effect, change effect and damage) and implications for the practice of therapists are given. Those are based on alternative interventions to NSC. The discussion of selected studies shows that the use of a NSC must be viewed critically, as it's use is often unconsidered. Moreover NSC can be beneficial as well as harmful to suicidal patients.

Psychotherapy with suicidal patients
In suicide prevention as well as in crisis intervention, rapid intervention is always important when suicidality is prevalent (Wolfersdorf and Etzersdorfer 2011). It is important to develop individual approaches that suit the current situation and the person seeking help. There is no general approach that promises success. Common practice and essential is not to be the only contact person for these patients, but rather to work in a team with psychiatrists, crisis intervention centers or other care facilities (Dorrmann 2009; Sonneck et al. 2016).

If suicidal patients turn to psychotherapists, one can assume a certain ambivalence regarding their suicidal intentions and thoughts (Aldenhoff 2017). The psychotherapist is then seen as an assistant who is supposed to provide help. Reichel (2018) advocates that, as a psychotherapist, dealing with suicidal patients is based on understanding and validating the other person and at the same time being a representative of the will to live.

The challenge for therapists when working with suicidal patients is to take the most therapeutically effective route, which at the same time should be as least restrictive as possible. If a suicidal restriction is already present, the development, care and achievement of stability and security in the psychotherapeutic relationship are of great importance (Bronisch 2014, 2017). Sonneck et al. (2016) note that only the relationship between psychotherapists and patients can loosen restrictions. It can be seen as a representative hope for the patients, which is of great importance to them. However, it is also important to strengthen or support the social system so that it can also become a source of hope and the reference/relief system does not only lie within professional care.

Due to the guarantor position of the practitioners and the associated responsibility, working with suicidal patients often triggers fears in practitioners. The use of NSV to minimize the fears of the practitioner should be avoided. Instead, transparency of the feelings triggered is important, which can also be seen as promoting relationships (Sonneck et al. 2016).

When it comes to the situation after a suicide attempt or self-harm, Reichel (2018) states that bewilderment and speechlessness are often the only "honest reaction" (p. 218). In this case, it is important not to ask why questions and not to make accusations, as these can fuel a new suicide (attempt). It is stated that it is important to convey joy that the other is still alive. What is important is honest and authentic concern.

Sonneck (2001) points out that the focus should not be on how one can stop a person from committing suicide, but rather on how life circumstances have to change in order to make life (again) worth living feel. This looks to the future, changes that need to be made can become visible and resources can be tapped.

The Non-Suicide Treaty
The focus of attention is then on the origin of the NSV intervention and the development towards a common intervention.

The original NSV as described by Drye et al. (1973) reads: "No matter what happens, I will not kill myself, accidentally or on purpose, at any time" (p. 172).

By using an NSV, the argument of Drye et al. (1973), practitioners and patients they already know have a common goal, namely securing life. In addition, talking about suicidality should be made possible and have a positive effect on the therapeutic relationship. The effectiveness is explained by the fact that no suicide occurred in 600 NSV completed with patients over a period of 5 years.

However, the researchers did not provide the relative numbers of how many or with whom NSV were agreed. Among other things, no statistical analysis has been performed and no criteria for the degree of suicidality have been established, which is why reproducibility is not possible (Drew 2001; Lee and Bartlett 2005; Page and King 2008; Range et al. 2002).

Drew (2001) highlights that Drye, Goulding and Goulding built the NSV on a transactional analysis approach. The authors saw the NSV as a statement of the adult ego state, which is responsible for taking responsibility and ensuring safety for life and limb.

In the 1970s, problem-centered or solution-oriented therapeutic approaches developed, which can be seen as an explanation for the establishment of NSV. Practitioners have noticed a correspondence between the use of NSV and cognitive or dialectical-behavioral therapy, because in both the patients' consent was given to be trained in their subject areas, i.e. to acquire new behavioral patterns and to practice them independently outside of therapy. In addition, crisis hotlines and crisis centers emerged at that time, in which NSVs were from now on also used for initial contacts (Edwards and Harries 2007).

From a psychodynamic perspective, NSSI often leads to the topics associated with suicidality being repeated or updated in the relationship with the psychotherapist. Kind (2011, p. 188) notes two common forms in this regard:

In a certain sense, the therapist comes too close to the patient through the pact, threatening his attempts to differentiate himself and his autonomy.

He tries to bring the area with which the patient is endangering himself under control, thereby actualizing the patient's feelings of surrender and powerlessness.

It is to be expected that a pact will be broken, especially in therapy with chronically suicidal patients. NSV affects patients "in areas of weakly developed psychological functions" (Kind 2011, p. 188). Breaking agreements should not be seen as a problem for the course of therapy, but rather requires appropriate handling of the behavior (Kind 2011). A resulting goal can be to communicate suicidal thoughts, ideas or impulses that arise or when these can no longer be controlled (Kind 2011). Stanley et al. (2017) emphasize focusing on suicidal urges in order to sharpen personal understanding of suicidality.

Lee and Bartlett (2005) have developed a theoretical discussion of the positive and negative aspects of NSV in Death Studies based on scientific articles. According to the authors, NSV can be perceived as relieving when the feeling that life is out of control arises. NSI can give people the feeling that control is possible, especially for people with personality disorders. One possible effect of NSI can be that patients are encouraged to talk about suicidality. Likewise, the therapeutic relationship can be negatively affected if patients no longer talk about their suicidality because of an NSI, out of fear of hurting the NSI. The result can be communication barriers and, as a result, the denial of suicidality, which poses a danger to the patient. However, some patients may also get the impression that the NSV only has a relief function for practitioners. The NSV should not be seen as an assessment tool. The assessment of suicidality must be carried out over a longer period of time and must follow diagnostic criteria. An NSV is a snapshot, while the assessment is to be understood as a process.

NSVs are used by some experts, although they have been only sparsely researched. The assumption arises that the use is based on impressions or experiences (Range et al. 2002). The next section deals with the presentation of study results.

The effectiveness of non-suicide contracts
Studies on the usefulness of NSV in everyday clinical practice or practice mostly paint the picture of the lack of evidence of suicide prevention through the use of NSV (Kelly and Knudson 2000; Reid 1998; Stanford et al. 1994). The author is not aware of a randomized control study like the one conducted in 1973 by Drye et al. known (Stanley and Brown 2012). Two studies from 2008 and 2017 are presented below.

Page and King (2008) conducted a study in Canada that evaluated the extent to which NSV was used by practicing therapists. 516 therapists with various basic professions were surveyed about their use or experiences with NSV. The survey was returned by 312 therapists and produced the following results: 83% of respondents have used an NSV (the majority of them therapists without a primary medical profession), although only 40% have received training in the use of an NSV.

The use of NSV was based on the assessment of suicidality. 31% of therapists who used an NSV stated that at least one patient attempted suicide or committed suicide despite using an NSV. If NSV did not occur, the majority of those surveyed attempted to accommodate the patients as inpatients (Page and King 2008).

The reason given by the therapists for using the NSV was that it showed concern and care. On the one hand, half of the therapists believed that NSI reduced the likelihood of suicide, while at the same time more than the other half of the respondents believed that it reduced therapists' anxiety. The respondents were divided on the question of liability protection through a non-suicide contract in the event of suicide. The study authors conclude that the respondents believe the use of NSI makes sense and advocate more intensive training in dealing with NSI and legal aspects (Page and King 2008).

In 2017, a randomized clinical comparative study by Bryan et al. (2017). The aim of the study was to compare the effectiveness of crisis response plans (= CRP) and NSV for suicidal thoughts or behavior. The study was conducted with 97 active soldiers in the American Army who had an emergency appointment due to crisis-like behavior. An NSV was completed with 32 people, a KRP with 32 people and an extended KRP with 33 people.

A CRP, as was carried out in the course of the study, is characterized by the fact that it is recorded in credit card format, is always carried by the patient and contains the following elements (Bryan et al. 2017) [translation by the author]:

personal warning signs to recognize them

personally helpful coping mechanisms or skills

Contact initiated caregiver(s) or contact the social network to get support

A CRP should be seen as a way to provide patients with instructions on what to do during a suicidal crisis. This covers the recognition of risk areas and related helpful actions, which can further contribute to increasing patients' sovereignty when they experience their self-efficacy (Bryan et al. 2017).

The results showed that there is no significant difference between an extended KRP and a KRP, which is why the results were combined into a category of 65 people. During the follow-up period of 6 months, three participants (4.9%) who received a CRP and five participants (19%) who received a NSV attempted suicide.

Patients with a CRP are 76% less likely to attempt suicide within the follow-up period. In addition to the lower number of suicide attempts among those participants with CRP, suicidal thoughts decreased more quickly and the number of days of hospitalization was reduced, which led the authors to conclude that the crisis response plan is more effective than the NSV (Bryan et al. 2017).

Bryan et al. (2017) mention that the use of CRP (as well as NSV) is based on the beliefs and experiences of the practitioners. There is currently no empirical data for the CRP form of intervention, which is why it will be necessary to investigate in the future which components of a CRP reduce the risk of suicide.

On the one hand, the study results underline the phenomenon of the popularity of NSV among practitioners, while on the other hand, other forms of intervention show better results in suicide prevention. It can be assumed that other parameters, such as the sustainability of the therapeutic relationship or support in the social network, influence effectiveness.

The impact factors of non-suicide contracts
Based on Leitner's classification of the impact factors of psychotherapy (2011), the categories of main, secondary, interactions and damage are then used to relate them to NSI.

The following points can be identified as the main effects of NSV:

Completing a NSV with an upright, stable relationship can and should strengthen the patient's self-control (Lazic et al. 2015).

Completing a NSV if the patient has an ambivalent attitude towards their suicidality can strengthen self-regulation (Lazic et al. 2015).

In cases of sudden suicidality and the need to react immediately, NSV has established itself as the most helpful and quickly available intervention (Edwards and Harries 2007).

The following points can be identified as side effects of NSV:

Completing a NSV can strengthen the therapeutic relationship if patients feel that the practitioners are genuinely interested in their well-being (Lee and Bartlett 2005).

Completing a NSV can endanger the therapeutic relationship if it triggers the patient's feelings of abandonment and powerlessness (Kind 2011).

The following points can be identified as the interaction effects of NSV:

Completing NSV is often expected to have a safety aspect for patients, but this cannot be assumed. The promise can be influenced by the "severity of the illness…, by unforeseeable, unexpected events at the moment of the promise and… [due to] individually variable handling of the obligation" (Lazic et al. 2015, p. 662).

The NSV is overrated and is therefore used across the board without reflection (Jacobs et al. 2010).

Interactions arise when practitioners use NSI as personal protection against legal consequences, even though they believe that NSI is of little help in preventing suicidality (Edwards and Sachmann 2010).

An NSV has no valid legal character and, according to common opinion, does not provide exculpatory protection in the sense of an evidentiary document or a legally valid contract in the event of an accusation. (Schiller (2011) is one of the few who classifies the conclusion of a NSV as positive for the legal proceedings in the context of (!) medical liability.) Protection in the event of an indictment can only be provided by detailed documentation as well as a thorough and procedural finding of suicidality (Edwards and Sachmann 2010; Jacobs et al. 2010; Lee and Bartlett 2005; Page and King 2008).

It may be that at the end of an NSI, the practitioner's vigilance or awareness of signs or hints of suicidality decreases (Jacobs et al. 2010).

A NSV is only as reliable as the existing therapeutic relationship (Jacobs et al. 2010; Lazic et al. 2015; Page and King 2008).

The following points can be identified as damage caused by NSV:

The function of NSV has changed from being part of an assessment and diagnosis to an intervention to protect against treatment errors (Edwards and Harries 2007).

Damage can occur if practitioners use the NSV to find a way to deal with their own fears or to reduce them. These fears can revolve around the well-being of the patient, but also about consequences in relation to the practitioner's practice of the profession. Patients often sense the fear or concern of the practitioners and promise to stay alive in the context of an NSI only to reassure the practitioners (Lazic et al. 2015; Lee and Bartlett 2005).

Damage can be caused if an NSI is completed in order to establish or strengthen a relationship (Lazic et al. 2015).

Damage can occur if a detailed, procedural assessment of suicidality is not made because a NSV is concluded. Likewise, failing to establish a treatment plan is harmful (Edwards and Harries 2007; Jacobs et al. 2010).

Damage can be caused if patients no longer dare to express suicidal thoughts or impulses due to NSI (Lee and Bartlett 2005; Stanley and Brown 2012).

Damage can be caused if, as a result of the NSV intervention, patients develop a feeling of authority on the part of the practitioner (Kind 2011).

Damage can occur if patients know that if they do not sign the NSV, they will be asked by the practitioners to begin inpatient treatment or will be admitted by them (Page and King 2008).

The Clinical Practice Guidelines for the management of adult deliberate self-harm of the Royal Australian and New Zealand College of Psychiatrists identify NSI as potentially harmful (Edwards and Harries 2007).

The paper makes it clear that there is an imbalance between the main impact factors and damage. The effect of depends heavily on the relationship with the patients, at the same time on their personality structure and also on the personal handling of the practitioners' fear for their patients. This calls into question the NSV as a "standard intervention". In the following, the insights gained are elaborated on implications for practice.

Me again:

Okay this was almost the full article. Who fully read it? Anyone? Not even the intelligence agencies monitoring what we are doing? Sad.

Do you think it is good or bad to post such content on here? I think science articles are way more nuanced than the black white media. Honestly I did not read it fully but there were very interesting parts. So share your experience with these contracts.

If it is too long for you I would suggest to read the summary and the last paragraph with the possible damage and possible positive impact of such contracts.
 
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Reactions: penguinl0v3s and edu0z
edu0z

edu0z

carried away by a moonlight shadow
Aug 25, 2021
552
really a good read (no joke). thanks for bringing it
 
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Reactions: noname223
Suicidebydeath

Suicidebydeath

No chances to be happy - dead inside
Nov 25, 2021
3,561
They sound like a terrible, one-sided idea. It's not even a contract, it's a waiver of responsibility.
 
Yarani

Yarani

When I deserve it the least, I need love the most.
Mar 29, 2024
168
I knew that article before and personally I read it differently
As I understood it, those contracts are to be viewed very critically
Focus should not be on preventing the suicide, but rather on strenghtening the support network
The contract is suspected to be used at least in part for the therapist's sake, which is to be avoided, instead the therapist should work on the relationship and voice their concerns
Its use could actually lead the patient to not speak up about suicidal thoughts out of fear of negative consequences
There is no real substantial evidence to support it
That's how I remember it

But maybe I'm wrong
And I'm currently too tired to fully read it again, but didn't want to leave it be either
So, sorry if I'm wrong
Maybe someone can check it
 
N

noname223

Angelic
Aug 18, 2020
4,676
I knew that article before and personally I read it differently
As I understood it, those contracts are to be viewed very critically
Focus should not be on preventing the suicide, but rather on strenghtening the support network
The contract is suspected to be used at least in part for the therapist's sake, which is to be avoided, instead the therapist should work on the relationship and voice their concerns
Its use could actually lead the patient to not speak up about suicidal thoughts out of fear of negative consequences
There is no real substantial evidence to support it
That's how I remember it

But maybe I'm wrong
And I'm currently too tired to fully read it again, but didn't want to leave it be either
So, sorry if I'm wrong
Maybe someone can check it
You could be right. I am a mass poster and no quality poster. Lol. But sometimes I am lackluster and don't put enough effort into it. Maybe someone esle can check it.
 
Yarani

Yarani

When I deserve it the least, I need love the most.
Mar 29, 2024
168
D
You could be right. I am a mass poster and no quality poster. Lol. But sometimes I am lackluster and don't put enough effort into it. Maybe someone esle can check it.
Don't worry about that
I didn't put in the effort to re-read it either, too exhausted
I think those contracts are not good interventions, neither scientifically nor intuitively
 
vadim

vadim

Disqualified From Being Human
Aug 10, 2023
103
I've never discussed suicide with a mental health professional and have thankfully never been hospitalised so I'm not familiar with all that goes on, but holy shit! I didn't know such a thing existed. It seems like where they're effective it's because of basically guilting people into not committing suicide, making suicidal people feel worse and potentially just kicking the can down the road.