“No-suicide” contracts evolved from a no-suicide questionnaire originally developed in 1973. The questionnaire was not designed as a contractual agreement between the client and the therapist but was intended to serve as a tool in assessing suicide risk, making subsequent treatment decisions, and providing a way to continuously monitor a client’s suicide risk over time. It was never meant as a way to control a client’s risk for suicide or as a method to prevent it, but that’s what it’s become and that’s where the problems began.
Known by many names, the no-suicide contract (or no-harm contract or contract for safety) is not a best practice and is not endorsed by Genesee County Community Mental Health. There are many concerns associated with the use of these contracts. Following is a list of the top 10 identified problems with “no-suicide” contracts:
1. There is no reliable data indicating any effectiveness of no-suicide contracts.
2. Staff are given a false sense of security that the client who signs a no-suicide contract will remain safe, ultimately increasing the risk to both client and staff.
3. Staff’s use of and reliance on no-suicide contracts causes a decrease in staff’s overall clinical vigilance.
4. Staff may mistakenly believe they have legal protection simply by using a no-suicide contract. In fact, they have chosen to handle a clearly identified risk in a clinically unsupported and ineffective way, thereby increasing their liability if harm should occur.
5. Staff must rely solely on a promise from a recently suicidal client, and it is very difficult to discern if such a client is able to be honest about his or her suicidal ideation. Even if the client is sincere in his or her promise to refrain from self-harm, the client’s clinical picture can change in a matter of moments and render him or her unable to keep that promise.
6. Due to the severity of their illness, the client may not be competent to enter into a no-suicide contract.
7. No-suicide contracts are being substituted for consistently repeated clinical assessments, careful assessment of risk, and a collaborative development of health and safety/crisis plans and relapse prevention/crisis plans.
8. The concept behind the use of no-suicide contracts is rooted deeply in the client-therapist relationship. Although no-suicide contracts are frequently used in emergency settings or in programs with a short length of stay, they are not useful since no client-therapist relationship yet exists.
9. No-suicide contracts initiated prior to inpatient discharges are often viewed as an indicator that the client is safe and ready for discharge, rather than completion of a thorough risk assessment that indicates the client has responded to treatment or that the client’s risk factors have decreased sufficiently to support a move from a high-risk to a low-risk category.
10. The use of a no-suicide contract does not provide a guarantee that an individual will not die by suicide.
The risk of suicide is mounting with the ever-increasing stress from ongoing problems with our environment, the economy, our community, and the world. However, for our client’s safety and our own, we must resist the temptation to utilize no-suicide contracts -- an agreement of this type does not provide anyone with any protection. Instead, our reliance should be on careful clinical documentation, thorough risk assessments, heightened attention to the presence of precipitating factors, crisis and relapse prevention plans, diligent monitoring, and consistent follow-up care.
Remember, you are not alone in the management of this client. Involve the client’s psychiatrist at the first hint that the client may be suicidal. Increase the frequency and the intensity of your contacts. Engage your supervisor and the other members of the client’s treatment team to elicit multi-disciplinary viewpoints. We all have a responsibility and a desire to prevent suicide, but we should depend upon effective methods of assessment and monitoring and not place our trust solely in a client’s promise.
American Psychiatric Association, Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors, located at: http://www.med.umich.edu/depression/suicide_assessment/APA%20Suicide%20Guidelines.pdf ; Goin M.D., Marcia, The "Suicide-Prevention Contract": A Dangerous Myth, located at: http://pnhw.psychiatryonline.org/content/38/14/3.full ; Kroll M.D., Jerome, No-Suicide Contracts as a Suicide Prevention Strategy, Psychiatric Times. Vol. 24 No. 8, July 1, 2007.
You need to login