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Monday, July 11, 2011

"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.

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