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:
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- 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.
- 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.
Thanks so much for writing this article. It’s such an important topic.
Jeni,
Thank you, I’m glad it was helpful to you.
Great article, very informative about an important topic!
Thank you. I’ll try those questions in conversation. Along with the contract we had the person talk to a suicide hotline, a trip to the hospital and weekly therapy starting tomorrow. I appreciate your advice so much. Thank you.
What if you didn’t know it was a bad idea to have someone sign a no suicide note…and you already had them do it? How do you undo it or do damage control?
Anonymous, you can simply talk to them about it. It could be helpful to ask them how they experienced being asked to sign a no-suicide contract. Did they find it helpful, harmful, or neither? Did they welcome it or resent it? And then you could tell them what you have learned and check it out with them. Most importantly, you can go over with them things that they can do, places they can go, and people they can call to stay safe.
Keep in mind that although no-suicide contracts are discouraged, that doesn’t mean they don’t help anyone at all. Some people do react positively to them. But many don’t, and no-suicide contracts don’t therapeutically direct the person on ways to stay safe. That is the key distinction between a no-suicide contract and a safety plan – a “contract” commits a person not to act on suicidal thoughts, and a safety plan helps the person come up with ways to not act on suicidal thoughts.
Thanks, Stacey, for sharing this info. It’s exactly the planning that Applied Suicide Intervention and Skills Training (through LifeWorks) teaches. I would encourage anyone (both professionals and non-professionals in mental health) who have an interest to check out their classes.
You’re quite welcome, Tamara. Thanks for providing the insight about ASIST. I have heard excellent things about their training, which appears to be useful for both lay people and professionals.
I agree they are useless pieces of paper. I know because it didn’t stop my daughter 2 1/2 months later. I never even knew she had made a contract (with an aunt) much less had even attempted. The aunt apparently thought I didn’t have a need to know. I found out about this contract a couple of days after my daughter passed when my son found it in a drawer.
This is the best material on suicide that I have found on the Internet. Finally!!!!
You are so kind to give me the positive feedback. Thank you! I’m glad to know the site is helpful. I will be posting more new things in the coming weeks, so please stay tuned.