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Unread March 5th, 2006, 08:12 PM
William Reid William Reid is offline
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Join Date: Jul 2004
Location: Texas
Posts: 105
Default Re: When the therapist screws up

Thanks for asking. This will be a little long. Sorry. For a more complete discussion (from my own viewpoint), folks are welcome to visit my website, go to the Columns/Full-Text page, and click on a last-year's article titled something like "No-Harm Contracts Redux."

No-harm "contracts" have enjoyed a lot of popularity. They were initially introduced (so far as I know) as parts of treatment, probably mostly informal communications in which the therapist gets the patient onto his or her wavelength in a sort of alliance against the mutual goal: symptom alleviation and, sometimes, survival. More recently, a lot of individual counselors and psychiatrists, emergency room docs, hospitals, and clinics have come to rely on written "contracts" not only to help patients but to decrease their own risk and liability for patients' suicides and other untoward behavior.

It's difficult to do studies which assess the usefulness of such "contracts" (notice how I insist on using quotation marks), but several have been done. In spite of anecdotal reports about "contracts" (which cannot reflect real effectiveness, though they may suggest patient or therapist satisfaction), every controlled study I've reviewed has found that the presence of such a "contract" does not reduce the risk of suicide. That's a very strong and important finding.

At least two studies (both from Minnesota, I think), also suggest that using "contracts" with emergency or crisis patients who have little relationship with the treater can create feelings of being "brushed off" (that is, the patient feels that the crisis counelor or ER doc used the "contract" to get him or her out of the clinic quickly rather than spend time with him).

Part of my point is that most truly suicidal patients don't think about their "contracts" when they are ready to kill themselves. Think about it: the morbid depression, etc., associated with true suicidality is such a strong influence on the patient's behavior that it overrides things like love of one's spouse and children, the well-being of one's family, strong religious prohibitions, personal wealth, etc. These people simply don't consider reasons to live; they see nothing except reasons to die. So-called "contracts" are no exception; they just aren't important when the chips are down.

Is it possible that a promise to a therapist could tip the balance toward survival, or get the person to call a therapist? Sure, it's possible. But it is foolhardy to bet the patient's life on that, for example by making the "contract" a major factor in deciding not to hospitalize, deciding not to seek consultation, deciding not to contact family or emergency authorities, or deciding to give a pass or discharge to a patient who otherwise may not be ready.

As most readers know, I do a lot of forensic work. The most common kinds of cases in my forensic caseload involve suicide. I see case after case, from all over the country, in which a clinician or team relied on a "contract for safety" when deciding to discharge the patient, refrain from hospitalizing the patient, or remove the patient from some kind of close observation status. It's often done as part of the effort to shorten the hospital stay, conserve staff resources, contain costs, or avoid seeing the patient more often. That's not only sad, it is often negligent.

So, my view, supported by the professional literature I believe, is that one may use lots of agreements with eligible patients (those who have the competence and ability to benefit from them) to assist in therapy, but when the chips are down, "contracts" are no substitute for careful (sometimes time-consuming) assessment, management, monitoring, and follow-up.
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