The no-suicide contract: possibilities and pitfalls.

FROM THE LITERATURE The management of the suicidal patient is one of the greatest clinical challenges facing mental health professionals. The overall suicide rate in the United States is 11-12 per 100,000, and more than 90% of those who complete suicide have diagnosable psychiatric disorders at the time of their death (1). A commonly used clinical strategy for managing suicidality, the no-suicide contract, first promoted by Drye et al. in 1973, has gained widespread acceptance as a useful tool for managing the at-risk patient (2, 3). In the era of managed care, mental health clinicians' reliance on use of no-suicide contracts is increasing (4); yet, in spite of its popularity there is disagreement as to its value, an absence of empirical support and efficacy data, and a dearth of guidelines for its use (3). What follows is a review of recent literature concerning the use of no-suicide contracts, including potential benefits and pitfalls. The no-suicide contract is also referred to as the no-harm contract or suicide-prevention contract. It is an agreement in which the therapist elicits a promise from the patient that if the patient experiences suicidal ideas or impulses, the patient will inform a health care provider, family member or friend, rather than engage in self-injurious behavior (3-5). Simon offers the following as an example of a no-suicide contract: We (clinician and patient) agree that you (patient) will call me if you find that you are worrying about harming yourself. If you feel you need immediate help and cannot reach me at that moment, you will go directly to the emergency room (specifically designated.) I will then be in touch with the emergency room. If you need to be seen between appointments, I will be available to see you (4, 6). While the agreement can be written or verbal, it is essential that the terms of the agreement be overtly stated, not implied (6). The refusal by the patient to agree to a no-suicide contract does not always mean that the patient is imminently at risk for suicide nor does a patient's acceptance of such an agreement indicate a lowering of risk, as patient's reasons for agreeing to a no-suicide contract may be conflicting and multidetermined (4, 7). A patient who is committed to acting out suicidal wishes may agree to a no-suicide contract simply to attain freedom to do so, while a manipulative patient seeking refuge in a hospital may refuse to agree to one, in order to gain admission (3, 4). Unfortunately, postmortem reviews of suicides found that suicide-prevention contracts had frequently been employed, suggesting that patients who agree to no-suicide contracts continue to be at risk, and should not reduce the need for clinicians to maintain a high level of vigilance (7). In fact, a serious limitation to the use of no-suicide contracts is that they may falsely reassure the therapist and result in decreased attention and concern about a patient's suicide risk (4). A viable therapeutic alliance is the basis, and may be prerequisite, for the establishment of a no-suicide contract. In addition, the process of contract negotiation may influence the therapeutic alliance in a positive or negative manner (3, 4). The formation of the contract can facilitate the development or enhancement of a therapeutic alliance via the open expression of caring by the therapist integral to the process of contracting (5, 8, 9). If however, while contracting for safety, the clinician is viewed as more interested in practicing defensive medicine than in the patient's welfare, the therapeutic alliance may be reduced (7, 9). For some clinicians, the patient's response to a no-suicide contract is seen as a measure of the status of the therapeutic alliance. A patient's refusal to agree to a no-suicide contract may suggest that the patient is potentially unable to control his/her impulses, and/or may be an indication that the therapeutic alliance is in a compromised state (3, 4). …