The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Patrick W. Corrigan, Benjamin G. Druss, and Deborah A. Perlick
Psychological Science in the Public Interest 2014, Vol. 15(2) 37–70.

Summary 

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma’s adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

The entire article is here.

When Medicine Is Futile

By Barron Lerner

The New York Times

Originally published September 18, 2014

Here is an excerpt:

The medical futility movement, which argued that doctors should be able to withhold interventions that they believed would merely prolong the dying process, did not experience great success. Physicians declaring things to be “futile” sounded too much like the old system of medical paternalism, in which doctors had made life-and-death decisions for patients by themselves. It was this mind-set that bioethics, appropriately, had sought to correct. Patients (or their families) were supposed to be in charge.

The problem was that the new system did not account for one thing: Patients often demanded interventions that had little or no chance of succeeding. And physicians, with ethicists and lawyers looking over their shoulders, and, at times, with substantial money to be made, provided them.

The entire article is here.

Rethinking Hospital Restraints

Thousands of patients are physically restrained every day for their own safety—but evidence suggests that the practice may be ineffective and even harmful.

By Ravi Parikh
The Atlantic
Originally published August 18, 2014

Here is an excerpt:

Most of us who have been hospitalized have never seen physical restraints, as they are rarely used outside the ICU. Examples include wrist and ankle belts, vests, mitts, and full-length side rails attached to the bed. According to Medicare guidelines, restraints should only be used to ensure the safety of patients and staff and should be removed as early as possible. There are only a handful of situations where Medicare and other physician groups recommend using restraints, including patient violence towards himself or others and a threat of a patient disrupting his or her life-saving therapy, such as a breathing tube.

The entire article is here.

The Self-Help Industry Helps Itself to Billions of Dollars

By Lindsay Myers
Brain Blogger
Originally published May 23, 2014

Self-improvement represents a $10 billion per year industry in the U.S. alone. In addition to high revenues, self-help also has a high recidivism rate, with the most likely purchaser of a self-help book being the same person who purchased one already in the last 18 months. This begs the question of how much good these self-help books and seminars are doing for consumers. If they are so effective at solving our problems, why do they usually result in a continuing stream of self-help purchases?

The entire story is here.

The Use of Telepsychology in Clinical Practice: Benefits, Effectiveness, and Issues to Consider

By Nicole Godine and Jeffrey Barnett
International Journal of Cyber Behavior, Psychology and Learning
DOI: 10.4018/ijcbpl.2013100105

Abstract

The use of various technologies in the practice of psychology has increased greatly in recent years in concert with increases in the use of these technologies in the lives of most individuals. E-mail, text messaging, chat rooms, and the Internet have greatly changed how many individuals communicate and maintain relationships. The psychotherapy relationship is no exception. The scope and practice of telepsychology, the use of the Internet and other technologies in the provision of psychological services, is reviewed along with relevant research that supports their use in the treatment of a wide range of conditions and disorders. Clinical, ethical, and legal issues and challenges are addressed and recommendations for the effective and appropriate use of these technologies in psychological practice are provided.

Article Preview

Mental health services can be delivered by e-mail, real-time chat, telephones, videoconferencing, cell phones, and websites (Grohol, 2003; Smith & Allison, 1998; Stamm, 2003; VandenBos & Williams, 2000). Synchronous modalities of communication, in which participants communicate in real time, include online chat, telephones, cell phones, and videoconferencing. Videoconferencing is a “technological procedure that allows individuals to see and hear each other on a computer monitor or video screen in real time” (Germain, Marchand, Bouchard, Drouin, & Guay, 2009, p. 42). It is different from real-time chat, telephone conversations, and cell phone conversations in that videoconferencing allows users to view and speak to each other in real time, whereas chat, telephones, and cell phones only allow the users to speak to each other (not view each other) in real time. Asynchronous forms of communication, in which there is a delayed response time, include e-mail, websites (which might be simply informational, or might offer contact with a mental health professional through e-mail), and text messaging via cell phones.

The entire article is here, behind a paywall.

Why are we still using electroconvulsive therapy?

By Jim Reed
BBC Newsnight
Originally posted July 24, 2013

Here are some excerpts:

The idea of treating a psychiatric illness by passing a jolt of electricity through the brain was one of the most controversial in 20th Century medicine. So why are we still using a procedure described by its critics as barbaric and ineffective?

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"For the first time we can point to something that ECT does in the brain that makes sense in the context of what we think is wrong in people who are depressed," Prof Reid says. "The change that we see in the brain connections after ECT reflects the change that we see in the symptom profile of patients who generally see a big improvement."

But passing electricity through the most complex organ in the body is not without risk. Many doctors think the side-effects of ECT can be so serious they outweigh any possible benefits.

The entire story is here.

It turns out empathy can be taught

By Craig Dowden
Special to Financial Post
Originally published July 7, 2013

There has been increased emphasis on empathy in the field of medicine in recent years. Empathy, it turns out, is directly related to key outcomes of interest to medical observers, including improved patient satisfaction, better patient adherence to proposed treatments, and increased well-being in doctors (including lower burnout). It has also been linked to a reduction in errors by doctors and fewer malpractice claims. As a consequence, the desire to enhance empathy in doctors is not only a noble and laudable goal, but also a valuable one from a bottom-line perspective.

Seeing the profound significance of empathy in medical settings, Dr. Helen Riess, an Associate Clinical Professor of Psychiatry at Harvard Medical School and Director of the Empathy and Relational Science Program at Massachusetts General Hospital, set out to explore whether it was possible to bring about observable improvements in physician empathy. Drawing on Daniel Goleman’s work in the area of emotional intelligence, as well as elements of the neuroscience of empathy, Dr. Riess designed and implemented an empathy training program for physicians.

The entire story is here.

Institutional Corruption of Pharmaceuticals and the Myth of Safe and Effective Drugs

Light, Donald W., Lexchin, Joel and Darrow, Jonathan J. , Institutional Corruption of Pharmaceuticals and the Myth of Safe and Effective Drugs (June 1, 2013). Journal of Law, Medicine and Ethics, Vol. 14, No. 3, 2013.

Abstract:  

Over the past 35 years, patients have suffered from a largely hidden epidemic of side effects from drugs that usually have few offsetting benefits. The pharmaceutical industry has corrupted the practice of medicine through its influence over what drugs are developed, how they are tested, and how medical knowledge is created. Since 1906, heavy commercial influence has compromised Congressional legislation to protect the public from unsafe drugs. The authorization of user fees in 1992 has turned drug companies into the FDA’s prime clients, deepening the regulatory and cultural capture of the agency. Industry has demanded shorter average review times and, with less time to thoroughly review evidence, increased hospitalizations and deaths have resulted. Meeting the needs of the drug companies has taken priority over meeting the needs of patients. Unless this corruption of regulatory intent is reversed, the situation will continue to deteriorate. We offer practical suggestions including: separating the funding of clinical trials from their conduct, analysis, and publication: independent FDA leadership; full public funding for all FDA activities; measures to discourage R&D on drugs with few if any new clinical benefits; and the creation of a National Drug Safety Board.

The entire article is here and available for download.

Interview with Peter Singer-Part I

By Giving What We Can Cambridge  |  Posted June 18th, 2013

In early May, Peter Singer visited Cambridge to give a talk on effective altruism and Giving What We Can at the Cambridge Union. Before the talk, a team from Giving What We Can Cambridge took the opportunity to discuss effective altruism and effective careers with Professor Singer. In the first part of the interview, published below, Singer answers questions on giving and altruism.

Effective Altruism and some of the key questions behind it…

GWWC: How would you see the relationship between effectiveness and altruism? Where would you place an emphasis? Do you see them as being equally important?

Peter Singer: They are both important. I think really what I'm interested in is the impact that we end up having on problems that need to be dealt with, let's say particularly the issue of global poverty. So it's like saying: if what you're interested in is how much water you get into a bucket then it depends on how wide or narrow the stream is as well as the force, the pressure, with which the water is coming out. You want altruism because that will mean that people do more, but you want it to be effective because that will mean it will have a bigger impact.

GWWC: In a nutshell, what is wrong with the morality exhibited by most people, and what is your alternative?

Peter Singer: What is wrong with it is that people tend to look predominantly at what they actually do as determining right or wrong rather than what they omit to do. Very often when we allow things to happen that we could have prevented, the consequences might be much more serious than infractions to moral rules that people take quite seriously. So I think that our attitude towards morality, to what is involved in living well, is warped by too much of a distinction between acts and omissions.

The entire story is here.

Interview with Peter Singer-Part II

By Giving What We Can Cambridge  |  Posted June 27th, 2013

In early May, Peter Singer visited Cambridge to give a talk on effective altruism and Giving What We Can at the Cambridge Union. Before the talk, a team from Giving What We Can Cambridge took the opportunity to discuss effective altruism and effective careers with Professor Singer.

In the second part of the interview, published below, Singer answers questions on effective careers.

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Applying effective altruism to career choices – the idea behind “effective careers”

GWWC: How would you define an effective career?

Peter Singer: An effective career is one in which you seek to make the biggest possible beneficial impact on the world. That would be the most effective career but not many people will reach this. What you see instead is people striving for the most effective career and changing their career choices in order to have a bigger impact, if not the biggest. Overall this is adding another dimension to what effective altruism is all about.

GWWC: Is there a set of stable criteria that identifies a career as effective or good? Or does it differ from person to person? Because ultimately it is very hard to anticipate what impact these big life choices will have. With all that in mind what advice would you give to university students and young people interested in making these decisions?

Peter Singer: The main advice is to think about your career as something you are going to spend a large amount of time and energy on – 80,000 hours – and therefore not just to fall into one career or the other but to make a conscious choice to end up in a career where you can make a significant difference, and expect to get some satisfaction and well-being from doing so. But that’s very general advice, I can’t give advice to students saying either you should become a doctor to go and help people abroad who need health-care, or you should become a scientist so that you can discover renewable energy that doesn’t emit greenhouse gases, or you should go into finance so that you can earn a lot of money and donate to these organisations. That decision is going to depend on the individual’s talent and character. Each individual has to think for himself or herself “what can I contribute and where can I have the greatest impact” and then commit to doing so.

The entire interview is here.

If Medications Don’t Work, Why Do I Prescribe Them Anyway?

By Steve Balt, Psychiatrist
Thought Broadcast Blog
Originally posted January 4, 2013

I have a confession to make.  I don’t think what I do each day makes any sense.

Perhaps I should explain myself.  Six months ago, I started my own private psychiatry practice.  I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions.  I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.

My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree.  But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry.  To put it bluntly, I’m not sure that psychiatric medications work.

Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait.  The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill.  In fact, it might even be a stretch to say that medications never work.  I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.

But here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response.  And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.

And then, of course, there are the patients who just don’t respond at all.  This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me.  But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response.  My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds.  I can’t be that bad at psychiatry, can I?

The entire blog post is here.

Study Compares Effectiveness of Telephone-Administered vs. Face-to-Face Cognitive Behavioral Therapy for Depression

The JAMA Network
Originally published June 5, 2012

Patients with major depression who received telephone-administered cognitive behavioral therapy (T-CBT) had lower rates of discontinuing treatment compared to patients who received face-to-face CBT, and telephone administered treatment was not inferior to face-to-face treatment in terms of improvement in symptoms by the end of treatment; however, at 6-month follow-up, patients receiving face-to-face CBT were less depressed than those receiving telephone administered CBT, according to a study in the June 6 issue of JAMA.

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“The findings of this study suggest that telephone-delivered care has both advantages and disadvantages. The acceptability of delivering care over the telephone is growing, increasing the potential for individuals to continue with treatment,” the authors write. “The telephone offers the opportunity to extend care to populations that are difficult to reach, such as rural populations, patients with chronic illnesses and disabilities, and individuals who otherwise have barriers to treatment.

The entire release is here.

Thanks to Tom Fink for this information.

In Therapy Forever? Enough Already

By Jonathan Alpert
The New York Times - Sunday Review - Opinion
Originally published April 22, 2012

MY therapist called me the wrong name. I poured out my heart; my doctor looked at his watch. My psychiatrist told me I had to keep seeing him or I would be lost.

New patients tell me things like this all the time. And they tell me how former therapists sat, listened, nodded and offered little or no advice, for weeks, months, sometimes years. A patient recently told me that, after seeing her therapist for several years, she asked if he had any advice for her. The therapist said, “See you next week.”

When I started practicing as a therapist 15 years ago, I thought complaints like this were anomalous. But I have come to a sobering conclusion over the years: ineffective therapy is disturbingly common.

The entire story is here.

Jonathan Alpert is a Licensed Professional Counselor in Pennsylvania.

Can Checklists Help Reduce Treatment Failures?

Samuel Knapp, EdD, ABPP

Director of Professional Affairs

John Gavazzi, PhD, ABPP

Chair, PPA Ethics Committee

Originally Published in The Pennsylvania Psychologist

Checklists have become a stable feature of safety science. Airline pilots, for example, will meet with other members of the airline crew and go through a checklist before they fly a plane. Checklists have been proposed for surgeons (Gawande, 2009) and other physicians (Ely et al., 2010). Could checklists be useful for psychologists? If so, when could they be useful?

Using checklists for complex procedures such as general medicine, surgery, or psychological services may seem overly simplistic. However, proponents argue that checklists have value because of the complexity of these processes. Although the items in the checklist may seem basic, the risk that decision makers will make “dumb” mistakes increases when they are confronted with large amounts of complex information, much of which may be contradictory or ambiguous. Checklists can help health care professionals in difficult situations by reducing reliance on memory alone and, more importantly, by allowing them to step back, reflect on, and rethink their initial decisions (Ely et al., 2010).

For most patients, checklists would be unnecessary. Most patients do well in therapy, and 50% of patients terminate therapy in 10 sessions or fewer. Nonetheless, a few patients have more complicated problems, take more time to report therapeutic benefits, drop out of treatment unexpectedly, or otherwise fail in therapy. Checklists may be especially helpful with these difficult patients.

Knapp and Gavazzi (2012) proposed that treatment outcomes can be improved by using the “four-session rule.” According to this rule, if a patient is not making gains at the end of four sessions or does not have a good working relationship with the psychologist (in the absence of an obvious reason), the psychologist should reassess the treatment with this patient. The four-session rule does not require transferring the patient. Instead, the rule requires psychologists to reconsider the case, perhaps using the checklist provided at the end of this article.

Often, the reasons for a lack of improvement in psychotherapy may be obvious. For example, a patient enters therapy with a minor depression, but then gets worse because of a sudden and unanticipated layoff from work. The reason for the deterioration is clear and the psychologist has almost automatically talked to the patient about new modifications to treatment in light of the new life circumstances. However, the mere deterioration in the patient’s condition in this situation does not appear predictive of a treatment failure.

We consider the “four-session rule” as a useful heuristic because it helps control for over-optimism on the part of the psychologists. Evidence suggests that many psychologists are overly optimistic about their ability to help patients. For example, Stewart and Chambliss (2008) found that psychologists worked with patients for a median of 12 sessions before concluding that treatment was not working and considering alternative steps. Nonetheless, Lambert (2007) claims that his algorithm can predict risk for treatment failure by the fourth session with a high degree of accuracy. These two sources suggest that psychologists should adopt a lower threshold for considering a case at risk of failure.

            We suggest using a checklist when treating a patient who falls into the “four-session rule.” After identifying an area of concern from the checklist, the psychologist can follow up in more detail, such as by answering some of the questions footnoted.

            We know of no empirical studies to validate the use of the checklist for those patients at risk of treatment failure. Nonetheless, it does represent an effort of self-reflection that is needed in difficult cases. Readers may send any feedback or comments on this checklist to Drs. Sam Knapp or John Gavazzi.

Four-Session Checklist

Patient Collaboration (What does the patient say?)

YES ___ NO ___ 1 Does the patient think you have a good working relationship?

YES ___ NO ___ 2. Do you and your patient share the same treatment goals?[1]

YES ___ NO ___ 3. Does the patient report any progress in therapy?[2]

YES ___ NO ___ 4. Does the patient want to continue in treatment? [3] If so, does the

                                    patient see a need to modify treatment?

Additional Reflections (What do you think about the patient?)

YES ___ NO ___ 5. Do you believe you have a positive working relationship with your patient? (Does he or she trust you enough to share sensitive information and collaborate?)[4]

YES ___ NO ___ 6. Is your assessment of the patient sufficiently comprehensive?[5] Do you need to obtain additional information?

YES ___ NO ___ 7. Do unresolved clinical issues of significant concern impede the course of treatment (such as Axis II issues, possible or minimization of substance abuse, or ethical concerns)?

YES ___ NO ___ 8. Does the patient need a medical examination?

Documentation

YES ___ NO ___ 9. Have you documented appropriately?

References

Ely, J., Graber, M. L., & Croskerry, P. (2011). Checklists to reduce diagnostic errors. Academic Medicine, 86, 307-313.

Gawande, A. (2009). The checklist manifesto. NewYork: Holt.

Knapp, S., & Gavazzi, J. (2012). Ethical issues with difficult patients. In S. Knapp, M. C. Gottlieb, M. Handelsman, & L. VandeCreek, (Eds.), APA handbook of ethics in psychology. Washington, DC: American Psychological Association.

Lambert, M. (2007). Presidential address: What have we learned from a decade of research aimed at improving psychotherapy outcome in routine care? Psychotherapy Research, 17, 1-14.

Stewart, R., & Chambliss, D. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181.

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[1] Do you understand your patient’s goals and how he or she expects to achieve them? How do they correspond to your goals and preferred methods of treatment? If they differ, can you reach a compromise? Does the patient buy into treatment? Did you document the goals in your treatment notes? What did the patient say was particularly helpful or hindering about therapy? Have you incorporated your patient’s perceptions into your treatment plan?

[2] Do you agree on how to measure progress (self-report, reports of others, psychometric testing, non-reactive objective measures, etc.)? Does the patient need a medical examination?

[3] If yes, why?

[4] Can you identify what is happening in the relationship to prevent a therapeutic alliance? Does the patient identify an impasse? Do your feelings toward your patient compromise your ability to be helpful? If so, how can you change those feelings? Have you sought consultation on your relationship or feelings about the patient? If so, what did you learn?

[5] Have you reassessed the diagnosis or treatment methods using the BASIC ID, MOST CARE, or another system designed to review the presenting problem? Are you sensitive to cultural, gender-related status, sexual orientation, SES, or other factors? What input did you get from the patient, significant others of the patient, or consultants (this is especially important if there are life-endangering features)?

The Therapist Will See You Now, via the Web

The New York Times
By Randall Stross

SEE a therapist without leaving your home?

In an article in the American Journal of Psychiatry, Dr. Thomas F. Dwyer, a Massachusetts psychiatrist, says he has practiced “telepsychiatry,” via video teleconferencing, for five years. Its “adoption by psychiatrists and patients,” he predicts, “will proceed quickly if the organizers cope with the irrational responses of some users.”

But wait: That article appeared almost 40 years ago. It told how microwave television signals were used to connect a satellite clinic to Massachusetts General Hospital in Boston.

Today, even with the rise of the Internet, virtual therapy hasn’t been widely adopted. But several start-up companies are trying to make Dr. Dwyer’s decades-old vision a workaday reality.

Therapy delivered over the Internet, says Lynn Bufka, a psychologist and staff member of the American Psychological Association, “may open access to those who might be reluctant to go to an office or to those who might be physically or psychologically unable to.”

Proponents of Internet-based therapy point to some research suggesting that it is effective for certain kinds of conditions, like depression and anxiety. Reporting in The Lancet in 2009, a team of researchers found that cognitive-behavioral therapy delivered remotely to depressed patients in Britain continued to show benefits eight months later.

But companies promoting online therapy must contend with uneven or absent support from insurance companies, Medicare and Medicaid. Most states don’t require insurers to pay for “telehealth” services (those not delivered in person). And any reimbursements can be less substantial than for in-person treatment. Medicare offers reimbursement only if providers are very scarce, as in rural areas.

One company that is trying to match patients to therapists online is Cope Today, based in Raleigh, N.C. Tania S. Malik, its chief executive, said the company, which began in 2010, worked with the North Carolina National Guard for a pilot test of its service. It has since opened its service to individuals, whom it attracts primarily with search ads that are keyed to phrases like “online counseling” or “treating anxiety.”

Cope Today lets prospective clients view a list of therapists and their availability for consultation via video, phone or online chat. It provides the first 10 minutes of a session free, then charges $35 for 15-minute increments.

The entire story can be read here.

"No suicide" contracts

Is a No-Suicide Contract an effective strategy?

By John D. Gavazzi, PsyD, ABPP

When presenting on ethics, a frequent question in Pennsylvania relates to the use of no-suicide contracts with suicidal patients.  No-suicide agreements are also known as “no-harm” agreements, safety agreements, or some other term indicating that the client will not harm him or herself prior to the next appointment.  The question is: Should I use a no-suicide contract with suicidal patients?

During workshops, my response has been, as a stand-alone intervention, I do not recommend this strategy for a number of reasons.

First, there is no research-based evidence that demonstrates the effectiveness of no-suicide contracts.  When a suicidal client signs the contract, there is no guarantee that this will motivate a patient from not acting on a suicidal ideation or impulse.

Second, some workshop participants commented that they use the contract as part of the assessment.  The rationale is that if the patient does not sign the contract, then the person is at a higher risk for attempting suicide.  Again, there is no research to support this assumption.  There may be many reasons for a patient not sign a no-suicide contract; none of which are related to the likelihood of the patient attempting suicide.

Third, the use of the term “contract” implies a legal element to the agreement.  There is nothing legal about the “contract”.  The use of a “no-suicide contract,” as a stand-alone intervention, does not provide a good risk management strategy.  A no-suicide contract does not mean that the psychologist has met the standard of care.

Fourth, depending on how it is used, a no-suicide contract may interfere with the therapeutic alliance.  A patient may interpret that the psychologist is more interested in risk management (avoidance of a lawsuit) than the patient’s own well-being.  This is especially true when the discussion of suicide is a prominent part of the patient’s clinical presentation or a frequent topic of therapy sessions.

No-suicide contracts may have their place within the larger context of therapy or suicide assessment and prevention.  Using some “quality enhancing strategies” may help with the development and use of a no-suicide contract.

First, the psychologist needs to complete an adequate assessment of suicide potential for a patient.  Issues such as depression, hopeless, helplessness, and a lack of connection to others are several important variables.  Thomas Joyner wrote an excellent book on suicide (Myths of Suicide) that may help psychologists with the evaluation process, although reading this book is not a substitute for sufficient training on this topic.

Second, any agreement, especially one relating to suicide prevention, usually works best when a psychologist incorporates patient input into its development.  Comparable to other aspects of psychotherapy, the more the patient collaborates in the process, the greater the likelihood of a positive outcome.  Suicide prevention is like all clinical interventions, which must be understood within the larger context of the unique therapeutic alliance with that person.

Third, the treating psychologist may want to reframe the agreement in less legalistic terms that promotes the potential for a successful treatment outcome.  One such example is a “Commitment to Treatment” form.  In a recent article from The Pennsylvania Psychologist, Norman Weismann captures the essence of this treatment form.  The “Commitment to Treatment” Form:

details the patient’s responsibilities in the treatment process, such as attending all the sessions, setting goals, and voicing thoughts and feelings openly and honestly, including feelings about whether the treatment process is working.  It also contains a statement that the patient agrees to make a commitment to living. In addition, the patient is asked to agree to implement a crisis response plan should suicidal thoughts increase in intensity and frequency.  The crisis response plan is a written list of actions the patient agrees to take when thinking of suicide, written on an index card (Crisis Card) that is kept available 24/7.”

This excerpt highlights the fourth essential point.  Any agreement relating to suicide prevention needs to incorporate a plan to prevent suicidal behavior.

The most important component for psychologists is to have appropriate education, training, and supervision or consultation when dealing with suicidal patients.  A “no suicide contract, ” in and of itself,  in unlikely to meet the needs of the patient or the standard of care.  A comprehensive approach is needed when working with suicidal patients.

I also recommend an excellent article by Stephen J. Edwards & Mark D. Sachmann entitled No-Suicide Contracts, No-Suicide Agreements, and No-Suicide Assurances: A Study of Their Nature, Utilization, Perceived Effectiveness, and Potential to Cause Harm in Crisis: The Journal of Crisis Intervention and Suicide Prevention.

Reference
Weissberg, N. C. (2011). Working with Adult Suicidal Patients. The Pennsylvania Psychologist Quarterly, 71(6), 8-10.