Many years ago, I was in my counseling center office conducting an initial session with a brilliant engineering graduate student. “Ted” was a gifted engineer and was a remarkably successful graduate student who had been sexually abused throughout his childhood by a next-door neighbor. As with many such patients I have seen over the years, a trauma history like Ted’s can leave a mark. Ted was utterly inept in his social interactions, he had severe bouts of depression, and was plagued by suicidal thoughts. Ted was extremely bright and had taken it upon himself to read the DC Mental Health Act and a few of my early articles in suicide prevention prior to our first meeting and to my alarm he knew these materials by heart!

When I asked him about his suicidal risk, Ted said, “…I think you would say that I am at an extremely high risk…I know about lethal means and have access to multiple methods for taking my life. As per your recent article, I think I am as high risk as they come; but no need to worry because I am not at imminent danger for hurting myself or others.”

Ted was a challenging patient and it felt like his goal was to maximize my anxiety while carefully choosing words that would probably make committing him to an inpatient setting unlikely (as per DC mental health statutes). Moreover, he seemed to “enjoy” my significant discomfort which only increased when he emphatically refused to sign the Counseling Center’s “No-Suicide Contract” (our routine intervention at the time).

In my desperation, I sought out a consultation with my Director and together we teamed up to coercively force Ted to sign the form or we would endeavor to commit him to an inpatient setting (even though we all knew that Ted could likely talk his way out of the commitment when DC Metro Police showed up to do their evaluation). With a lot of pressure, Ted thus grudgingly signed the form promising to be safe until his next appointment with me. But as he left my office with withering glare he said, “…this is the last time I ever sign this damn form…next time you need to do better!” And he promptly slammed the door of my office as he left.

A few years later, as the Associate Director of the Counseling Center, I was called into a session late on a Friday afternoon (why are such emergencies always late on a Friday afternoon?). An earnest but inexperienced clinical extern in training was struggling with a very worrisome case. “Janet” was a 20-year-old nursing major who reportedly had access to a lethal stash of pills and was firmly on the fence about her prospective safety over the weekend. Much like my situation with Ted, the extern clinician was struggling to get Janet to sign the agency’s No-Suicide Contract. And again, I saw an earnest but inexperienced clinician who was maximally anxious with a patient who seemed completely disinclined to decrease the clinician’s anxiety about her risk.

With my increasing knowledge base in suicidology, and more years of clinical experience under my belt, I engaged Janet in an exasperating conversation about her risk of suicide and whether we would have to call the police to have her committed against her will to an inpatient setting because of our concerns.

Finally, in a rather untherapeutic tone of exasperation I bluntly asked Janet, “…please give me a number from 1 to 100 which reflects your certainty of being safe over the weekend and attending your next appointment here Monday AM; 1 = no certainty and 100 = absolute certainty.” The client mulled over my question and grudgingly muttered, “51” with a familiar icy glare that reminded me of Ted. The exchange left me feeling empty—I guess we “won” (?) the battle, but in so doing might we lose the larger war (which could be a prelude to a fatal suicide outcome).

 

*  *  *  *  *Many senior clinicians like me can recount many similar such “war stories” of challenging clinical cases. But then these words are curious: war stories? And battles? Am I not talking about psychotherapy which should be the antithesis of conflict and battle? In short, yes. But sometimes psychotherapy with a suicidal patient can feel like a kind of psychological battle, a war of determined wills. Patients like Ted and Janet are fighting for their “right” to self-determination vs. the clinician who is fighting for a widely held value that within a civil society that we simply cannot “let” people take their own lives!

These cases came to mind as I read a recent listserv discussion of Safety Planning and malpractice liability. Reflecting on decades of work in mental health, one of the most remarkable evolutions within clinical practice has been a clear move away from “No-Harm Contracts” (otherwise known as “No-Suicide Contracts”). Back in the day, “contracting for safety” was the bedrock of mental health care for suicidal risk.

When I worked as a psych tech on an inpatient unit, no patient was discharged until they signed their No-Harm Contract, promising to not kill themselves prior to their next outpatient appointment. Yet even as a young mental health professional, the whole idea of No Harm Contracting made absolutely no sense to me! Getting someone to “commit” to not killing themselves with the implicit and sometimes explicit threat of dire alternatives (ranging from being committed to an inpatient setting, up to being put in 8-point restraints in a seclusion room in such a setting) just made no sense. Even as a novice, I knew that this whole dynamic was not about therapy. Rather, it was about power and control. And for many with lived experience, their sobering reflections on these standard practices are not pretty, as they describe feeling invalidated, shamed, coerced, and bullied by members of the mental health profession.

Thank God for Barbara Stanley and Greg Brown, who in the 1990s turned the notion of No-Harm Contracting on its head with their development of the “Safety Plan Intervention.” Around the same time, David Rudd and later Craig Bryan similarly developed an intervention called “Crisis Response Planning” which further added tremendous therapeutic value to the clinical engagement of a suicidal patient. Relatedly, and somewhat later still, I developed the use the CAMS “Stabilization Plan” which is central to this effective suicide-focused clinical framework.

These interventions are conceptual cousins and have proven themselves to be effective both in clinical practice and within rigorous clinical trials. What they have in common is an overt emphasis on what the suicidal person will do vs. promising what they will not do in a dark moment. Completion of these interventions by their nature is collaborative rather than adversarial—the dyad works together to identify triggers, coping strategies, and ways of decreasing access to lethal means while increasing access to crisis resources and/or caring providers.

At the end of the day, psychotherapy with a suicidal person can sometimes feel like a battle; a war over the patient’s autonomy and self-determination vs. doing what is in the best interest of the patient from the larger perspective of a civil society. What I have come to see over my many years of experience is the critical need to understand and validate the suicidal person’s experience. In so doing, a therapeutic door can be opened that we may choose to walk through together to see if there is a reasonable way to save this person’s life.

My clinical war stories and the wisdom of clinical research ultimately led me to develop CAMS with an overt emphasis on empathy, collaboration, honesty, and a singular focus on suicide. CAMS may not always “win” the suicide war, but its development and increased clinical use around the world has given many suicidal people—and me—a kind of peace that we can live with…