The practice of getting our clients to fill up a non-suicide contract is common in risk management work. Whenever there is a risk of suicide, we tend to be compelled to get our clients to fill up this form, which states that they would not be attempting suicide as it is illegal in Singapore. Often, there is a generic form that social workers would be able to use.
My grouse with the non-suicide contract is that it seems to be a practice that is more focused on "covering our backsides" as opposed to ensuring that our clients are safe. We work towards filling up the forms, and then develop a false sense of safety as long as the form is filled up, because we feel that we have done our part. If anything were to happen, at least we can show others that a non-suicide contract had already been done between the social worker and the client.
Frequently, I also find that a lot of my clients hesitate in filling up the form. One response that I had from a client many years was particularly significant:
"Here I am, really feeling shitty about myself; and here you are trying to force me to fill up this form"
The process of building rapport and assessing risk with the clients, to a large extent (for me) faces a rather jarring ending, when we try to convince our clients to fill up a non-suicide contract.
Conversations I had with various practitioners, such as Loretta Pederson (who has a video on utilizing narrative ideas with people experiencing suicidal thoughts), I realised that the focus should instead be on fostering a collaborative plan of safety that was resonant in the conversations we were having with our clients surrounding risk.
At the same time, the collaborative safety plan should also identify the skills and values of the people that we work with. These are important resources and anchor points that are resonant to our clients' experience, as opposed to strengths that are practitioner defined.
Examples of questions that I begin using to identify such skills and values include:
"When you were able to prevent yourself from going up to the 10th floor and jumping, what value or belief stopped you? Where does this value come from"
"This thing (The precipitating event/stressor) happened last week; so how were you able to keep yourself alive and safe until now? How would you name this ability?"
"Seems like your friend here wants you to be safe, why do you think he wants you alive? What about you is important to him?" (within a systemic frame, I find it useful to bring in key allies and supporters of my clients in our sessions).
Of course, as a social worker, I also believe that we should not shy aware from questions that would help us identify the nature of the risk. I will not go into detail about that aspect much, but suffice to say that the following CPR model is one that I have been using for quite some time:
C - Current situation (which also involves reflecting about our client's immediate affect following a traumatic stressor)
"What plans do you have now about ending your life?"
P - Past attempts / History
"Have such thoughts disturbed you before? What happened then? What did you do? How were you able to refrain from hurting yourself?"
R - Resources (and alternative storylines)
"Who are the people who would be upset should anything happen to you? What do they value about you?"
"What were some things that you were able to do, that have been helpful in keeping you safe?"
Through a process of identifying risk and alternative storylines of responses to risk, we can also express curiosity about situations which need more attention. For e.g.:
"Looks like you know what to do in the day when these thoughts bother you, and usually you are able to keep yourself busy in the morning. But you mentioned that the thoughts come and bother you when you are about to sleep. What are possible ideas you have about responding to these thoughts at this time?"
"What has been useful? What are some new ideas that you would be open to try?"
In these situations we can also provide suggestions or creative ideas that may be resonant to our clients' unique worldviews. E.g.:
"You earlier talked about how your religion has been keeping you going; would prayer be useful for you at this time when the thoughts could get overwhelming? What are some prayers you might recite?"
A collaborative safety plan should place importance on resources and responses that are identified by our clients, and resonate with their unique perspectives. We wouldn't push for someone to write a journal, if this is a practice that is totally alien to him. It can involve efforts not only by the client, but also other important allies in the family ecosystem, as well as the helping professional.
The following is a safety plan that might be developed in the process (not based on any real life person of course):
We have all decided that Henry should keep himself safe for the following reasons:
1. ____________
2. ____________
3. ____________
This safety plan is drawn up because we are all concerned about Henry's safety, especially when these thoughts of "worthlessness" and "pain" come to disturb him. We have all agreed on the following points and will review them again by ________.
1. Henry would call his brother John, should the thoughts come and disturb him. John is aware of this and would be extra vigilant in answering these phone calls.
2. Henry has found it useful to keep his morning busy. He is able to do this through exercise which include morning walks and runs, and also doing push ups at the exercise area. He would be doing this exercises and will update about its usefulness when we review the plan.
3. The thoughts come and bother Henry the most when he is about to sleep. We have identified some possible ideas to manage these thoughts. e.g. drinking a hot drink before sleep, watch a youtube comedy video one hour before sleep. If the thoughts become overwhelming, Henry is able to call John immediately. He can also contact the SOS hotline at _______. We will review the usefulness of these strategies in the next meeting.
4. We have discussed the possibility of hospitalisation should the thoughts be really overwhelming. We have also come to an agreement that this is a last resort and requires further discussions between Henry and John. Henry and John are confident that hospitalisation will not happen due to Henry's value of "wanting to make a difference in others' lives". Henry wants to make sure that he is able to contribute to the lives of others, and would remember this value should the thoughts be overwhelming.
5. The social worker would also be making "check-in" calls at the following times: ________. The purpose of these calls are to ensure that Henry is safe. Henry will also tell us the extent of how the thoughts have been disturbing him, and any useful strategies that have been identified.
The following team members are committed to support this safety plan: (Names and signature of all involved.)
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