Article: Sign on the Dotted Line: No-Harm Contracts in the Clinical Setting

[Therapist4Chnge]

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I wanted to start a discussion on the article found HERE. I copied it below for easy reference.

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Sign on the Dotted Line: No-Harm Contracts in the Clinical Setting

When working with a depressed patient, the risk of suicide is a very real and present concern. Health care professionals need to be prepared to respond swiftly and effectively. The literature suggests a multi-faceted approach to assess and address the self-harm risk, with one element being the implementation of a "no-harm contract". The document in its simplest form is a written agreement between the patient and the health care professional that states the patient's willingness and commitment to notifying a relative or healthcare professional of their intent to harm themselves, instead of engaging in harmful behavior.

No-harm contracts are a common tool utilized in the clinical setting, though there are mixed opinions about their effectiveness, particularly in regard to customized forms. In addition to variation between contracts, many healthcare professionals do not receive any formal training in regard to the proper administration of a no-harm contract, so proper use of the contract may be problematic. It is best for facilities to use a standardized contract so they can train all of the applicable professionals on one document, and have consistency through departments. It is important that professionals make themselves comfortable with the document and can talk about it in-depth if necessary, as being unprepared may suggest that it isn't important or that you don't care.

A no-harm contract is an opportunity for a discussion of the importance of the patient's safety, providing behavioral alternatives to harming themselves, and for the patient to ask clarifying questions or explore concerns about their own safety.

The presence of a healthy therapeutic relationship can provide a safe environment for the patient to share their thoughts and concerns. The no-harm contract is often advocated as an opportunity to build a therapeutic alliance, though some believe the therapeutic alliance must already be present to be efficacious. The professional needs to inquire about the patient's thoughts about the contract, as some patients may view the contract as an escape behind legalese, rather than a genuine attempt to build a therapeutic alliance.

Things to Keep in Mind When Using a No-Harm Contract

• Having a no-harm contract in addition to other assessment measures and professional follow-up may be the safest course of action for an at-risk patient.

• Patients can vary greatly in educational backgrounds, so it is important to use clearly defined terminology that is comfortable and understandable to the patient, and confirm with the patient throughout that they understand what you are saying.

• A healthy therapeutic relationship can contribute to better compliance, though lack of a therapeutic relationship can have the opposite effect.

• Having an open dialogue can allow input from the patient and health care professional, which may build a ‘buy-in' for the patient.

• A no-harm contract should not be an automatic response to every situation where there is a possible self-harm risk, as this may diminish the effectiveness of the contract.

• The no-harm contract can be seen as coercive, so it is important to discuss the contract with the patient and let them process their thoughts if needed.

• There is no proven legal safety in solely utilizing a no-harm contract as a means to shield yourself from a lawsuit, so a combination of documented interventions is suggested.

• Be aware that the patient may lull the clinician into lowering safety measures by signing a contract and behaving for a short time, which allows the patient greater opportunity to harm themselves once the restrictions are relaxed.

References​

Davidson, M.W., Wagner, W.G., & Range, L.M. (1995). Clinicians' attitudes toward no-suicide agreements. Suicide and Life-Threatening Behavior. 25 (3), 410-414.

Egan, M.P. (1997). Contracting for safety: A concept analysis. Crisis. 18 (1):17-23.

Kelly, K.T., Knudson, M.P. (2000). Are No-Suicide Contracts Effective in Preventing Suicide in Suicidal Patients Seen by Primary Care Physicians? Archive of Family Medicine. 9:1119-1121.

Kroll, J. (2000). Use of No-Suicide Contracts by Psychiatrists in Minnesota.
American Journal of Psychiatry 157:1684-1686.

Miller MC, Jacobs DG, Gutheil TG. (1998). Talisman or taboo: the controversy of the suicide-prevention contract. Harvard Review of Psychiatry. 6:78-87.

Range, L.M., Campell, C., Kovac, S.H., Marion-Jones, M., Aldridge, H., Kogos, S., & Crump, Y. (2002). No-suicide contracts: An overview and recommendations. Death Studies, 26, 51-74.

Richards, K. & Range, L.M. (2001). Is training in psychology associated with increased responsiveness to suicidality? Death Studies, 25, 265-279.

Stanford, E.J., Goetz, R.R., Bloom, J.D. (1994). The no harm contract in the emergency assessment of suicidal risk. Journal of Clinical Psychiatry. 55, 344-348.

SIEC: Suicide Information & Education Collection. (2002). Centre for Suicide Prevention. Canadian Mental Health Association. 49, 1-2.
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[Psychmeout]

I have used an "unstructured" version no-harm contract. When I say "unstructured" I mean that it does not seem as thorough as the one that this article is proposing. In my experience with patients who express that they want to commit suicide, it actually works pretty well because there is something about "signing a contract" that makes patients feel that they obligated NOT to commit suicide. However, I am not sure how well this would work on someone who has a substantial history of suicide attempts or who has reached the final stages of contemplating suicide (i.e., one who is content with their decision, has planned how their belongings will be dispersed among family members, etc.).

 

[Therapist4Chnge]

Good points.

I'm not wild about the universal use of NHCs, as people tend to use them almost as an after-thought. "Oh, this person is self-harm risk, we should have them sign a NHC." I think when used appropriately, they can be a nice adjunct to other interventions.

I tweaked the article because my initial draft was much more of a Pro's and Con's discussion with a greater focus on the literature, though I thought that may take away from the 'usability' in this setting, so I hacked it up and tried to provide some useful tidbits that people can hopefully think of the next time they are presented with a NHC consideration.

 

[thewesternsky]

I've heard about these being used with BPD patients quite often. I'm not sure how I feel about using it as a routine tool, but on a case-by-case basis it seems it might be useful.

 

[sarahkristy117]

I use these with a few adolescent patients at the residential treatment center where I work. I think you have to know the individual to assess whether it will help or not. I have one resident who benefits a lot from these. The process of her actually taking the pen and writing out her contract herself is a therapeutic process for her. It's a step she takes to ensure her own safety when she feels that she is helpless to take any other steps...

It's great for her but the key is that she write out the contract with staff and then sign... rather than just scribbling a signature.

This may not work in a traditional therapeutic setting but it does work well in a an inpatient setting at times. (at least in my experience)

 

[myelin]

Good post. As a tech on an inpatient unit, I used a verbal no-harm contract with SIB, suicidal, and aggressive patients. I found it useful to establish rapport once the patient stepped foot onto the unit and then verbally establish a no-harm contract with them. That way, when and if the person were to try to harm themself or another patient, I could use that get through to them. Most of the time it would work, but sometimes the patient was soo keyed up that nothing but mechanical and pharmaceutical restraint would work.

As far as the actual no-harm contract on paper, the therapist would go over it and have the patient sign it upon their first meeting.

 

[McDoctor]

I'm not a psychiatrist, but on a very basic level the idea irks me. This seems to be a legal disclaimer which allows me to abandon the patient should his/her condition worsen and the patient act on suicidal tendencies, similar to "narcotic contracts", which I guess allow me to abandon a patient when the diagnosis moves from a mechanical one (pain) to a psychiatric disorder (opioid dependency).

I don't use narcotic contracts, and I've never really seen "no harm contracts". What are the typical consequences when a patient breaks the agreement?

 

[sarahkristy117]

I don't use narcotic contracts, and I've never really seen "no harm contracts". What are the typical consequences when a patient breaks the agreement?

In my experience, the contract is not something that is legally binding or something that incurs punishment if broken. When a resident "breaks" the safety contract, it doesn't have a consequence (besides going to the ER). The point of the contract in my setting is to reinforce a safety agreement, something that the resident can take part in.. something that helps them to put into action their desire to stay safe... the process of writing and signing it assists them in giving their desire to stay safe a "voice" so to speak...

Their is obviously a process that occurs when a resident vocalizes or signals that they are feeling unsafe or suicidal... writing and signing a safety contract is part of that process if they wish to stay in the residential treatment center rather than being brought to the hospital...

This is only in the case of a IRTP though

 

[Therapist4Chnge]

Pretty much what sk said....avoiding a 72-hr Baker Act. If they are in that setting already, it could involve other things, though I would be really hesitant to 'punish' someone for breaking it, as that may do more harm than good (no pun intended). Something like a 'sitter' to monitor them 24/7 could be used.

 

[PsyDGrrrl]

A no-harm contract will do nothing for you in court, however, if your patient kills themselves and someone wants to sue you or question your care. A detailed (documented) risk assessment will go a lot farther in protecting you, as well as documentation about your thinking process in why you make the decisions you do if you choose not to hospitalize a potentially suicidal patient.