The Case Against No-Suicide Contracts

Suicide prevention experts discourage the use of no-suicide contracts. With a no-suicide contract, the client signs an agreement promising not to do anything to harm or kill himself or herself within a specified period of time. The contract may also “require” the client to take some specified action if they want to act on suicidal thoughts, usually going to an emergency room or calling 911.

The no-suicide contract has quite a few disadvantages that can harm the therapy and the client:

• • There is no evidence that no-suicide contracts actually work. In fact, there is quite a bit of evidence that they do not work. One study found that of people who attempted suicide in a psychiatric hospital, 65% had signed a no-suicide contract. A survey of psychiatrists found that  of those who used no-suicide contracts, 40% had a patient die by suicide or make a serious attempt even after signing such a contract. 
    
    
  • Many clients feel mistrustful of therapists if asked to sign a no-suicide contract. Some clients perceive these contracts to be a way to protect the therapist, not the client.  
    
    
  • If a client promises not to attempt suicide, what happens when the client actually does attempt suicide? Some clients may withhold such information, out of fear that the therapist will be angry at the client for having broken their promise. Yet, to most effectively help, the therapist needs to know that the client attempted suicide. The client needs to feel free to share such information without fear of rebuke. 
    
    
  • No-suicide contracts do not actually protect a therapist from a malpractice judgment, should a lawsuit occur. 
    
    

  If suicide really could be prevented with a simple contract or agreement, then suicidal people would never need our help. A person stricken with intense suicidal thoughts would, by virtue of the no-suicide contract, call on their strengths, resources, and self-control to manage their impulses and stay safe on their own. The task of therapy is to help build those assets, not to presume that they already exist.

  Safety Planning with Suicidal Clients

  For these reasons, I teach my social work students not to use no-suicide contracts. The more helpful alternative is safety planning.

  A safety plan, created in collaboration with the client, provides steps the client can take to stay safe. Gregory Brown, PhD, and Barbara Stanley, PhD, described the various components of their safety plan intervention here. Their safety plan centers on clients’ doing the following:

  • Keeping their home environment safe (for example, removing firearms).
    
    
  • Recognizing warning signs that a suicidal crisis may be approaching.
    
    
  • Coming up with ways to cope personally with suicidal thoughts, without calling on other people or resources.
    
    
  • If that doesn’t work, identifying friends, family, and other people to contact for help or distraction.
    
    
  • And if that doesn’t work, identifying mental health agencies and other places (such as a hospital emergency room) that the client can call or visit.
    
    

  I may write more about safety planning , but in the meantime, see this article on another site: Safety Planning in the Emergency Department.  

  You can download a blank safety planning form at www.suicidesafetyplan.com.

  © Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide. Photo and graphic purchased from Fotolia.com.