No-suicide contracts—why won’t so many clinicians let these go?

[futureapppsy2]

Bit of a rant, but it’s been known for years that making a suicide person promise that they won’t hurt/kill themself doesn’t generally result in any sort of effective suicidal prevention, especially if there’s no or a very minimal safety planning attached to that contract (I’ve seen one case where the sole safety plan attached was “call someone” and another was “call a doctor”—no contact information for easy access, not even a specific name, no alternative for what the patient should do if said person didn’t pick up, etc), but people will not stop these in favor of actual safety planning. Is there actual liability protection in doing these anywhere in the US? Or does it just relieve clinician distress?

---

Members don't see this ad.

 

[Egg122]

People have a false sense of security that it will protect them legally if they are sued. They do not hold up in court though.

 

[futureapppsy2]

People have a false sense of security that it will protect them legally if they are sued. They do not hold up in court though.

Yeah, that’s always been my understanding—that they offer no meaningful clinical or legal value to either the clinician or patient. That’s why it baffles me that they are still so common, and a lot of programs are still training trainees to use them.

 

[R. Matey]

Yeah, that’s always been my understanding—that they offer no meaningful clinical or legal value to either the clinician or patient. That’s why it baffles me that they are still so common, and a lot of programs are still training trainees to use them.

I mean, some people teach Adlerian therapy as if it's valid. Old habits die hard, I suppose.

 

[Sanman]

Yeah, that’s always been my understanding—that they offer no meaningful clinical or legal value to either the clinician or patient. That’s why it baffles me that they are still so common, and a lot of programs are still training trainees to use them.

Because someone took a CME a decade ago that suggested this and decided that it was all the training they needed on risk management. Now that person runs the department.

Pretty much everything done related to suicide is in the name of managing legal liability, not anything clinically meaningful. Suicide safety plans are a ton of paperwork, which is why they are often filled out poorly and I need to redo all of them.

 

[Therapist4Chnge]

No Harm Contracting can be helpful, but the vast majority of ppl don’t implement them correctly, so they often cause more problems than they help. They CAN* be viewed as coercive by the patient, but if they are used in conjunction w developing a safety plan, reinforcing coping skills, shared across providers, etc….then they could be helpful. There are a lot of downsides to them, and I haven’t recommended them for quite awhile.

Being 100% honest, I haven’t utilized them in probably a decade, and probably won’t again bc they invite liability and problems. In private practice, I purposely screen out higher acuity cases for my private practice.

*fixed

 

[albatross_at_crossroads]

No Harm Contracting can be helpful, but the vast majority of ppl don’t implement them correctly, so they often cause more problems than they help. They can’t be viewed as coercive by the patient, but if they are used in conjunction w developing a safety plan, reinforcing coping skills, shared across providers, etc….then they could be helpful. There are a lot of downsides to them, and I haven’t recommended them for quite awhile.

Being 100% honest, I haven’t utilized them in probably a decade, and probably won’t again bc they invite liability and problems. In private practice, I purposely screen out higher acuity cases for my private practice.

I've only heard about these contracts in the context of the intensive one year DBT program that runs at a local hospital.

Would you recommend any resources for effectively developing a safety plan?
I would also be interested in when/how you screen out higher acuity cases for PP - do you do this in the free consultation, and then refer them to emergency/ other providers?

 

[borne_before]

Eli Lebowitz, has an interesting technique as part of the Supportive Parenting for Anxious Childhood Emotions (SPACE), protocol for addressing parental accommodation. When you start to pull back parenting accommodation of anxiety (e.g., I know being by yourself is scary, but I know you can handle it and I am no longer going to let you follow me to the restroom anymore), kids will make threats of self harm or endorse suicidal ideation. It's easy to see how this is a little but of a emotionally blackmail/coercive dynamic.

He basically recommends recruiting others and putting kids on a 24/7 suicide watch. But, it's essential to recruit others from outside the home. For instance, neighbors, parents of kids, aunts, uncles, grandparents, etc. He frames it as a way to show a kid how much support they have and how loved they are. You stop the watch when a kid assures you and you're sure that they can be safe. If that doesn't happen then you send them to inpatient/hospital (it's always an option).

But, it's interesting because I see this dynamic a lot - especially in the DMDD/ODD/ADHD sphere. Kids with ADHD and dysregulated emotions often engage in tyrannical behavior that they will not do in proximity to people outside of their immediate household. There is a social worker who recommends recruiting others for this type of behavior - like having an uncle or coach call the kid when they get like this.

I find it also interesting because so many disorders are a secret and this helps bring them to the immediate surroundings.

 

[cara susanna]

I've only heard about these contracts in the context of the intensive one year DBT program that runs at a local hospital.

Would you recommend any resources for effectively developing a safety plan?
I would also be interested in when/how you screen out higher acuity cases for PP - do you do this in the free consultation, and then refer them to emergency/ other providers?

DBT requires that the patient take suicide off of the table for the duration of the treatment. If the patient repeatedly engages in suicidal or parasuicidal behavior, they would eventually be "unilaterally discharged."

It's not quite the same as a no suicide/harm contract, though.

 

[futureapppsy2]

I've only heard about these contracts in the context of the intensive one year DBT program that runs at a local hospital.

Would you recommend any resources for effectively developing a safety plan?
I would also be interested in when/how you screen out higher acuity cases for PP - do you do this in the free consultation, and then refer them to emergency/ other providers?

Safety plans are definitely used outside of DBT contexts. They involve making a detailed step by step plan with the patient of strategies they can use to cope with SI. They typically include things like basic coping at the lower levels (read, take a walk, listen to peaceful music, meditate, etc) to reaching out to reliable social supports to reaching out to reliable social supports about suicidality to calling crisis hotlines to reaching out to providers to going to the hospital. They need to be detailed (list specific names and phone numbers), have backup options (who do they call if Person A doesn’t pick up, etc), and have to be readily physically or electronically accessible (some people suggest putting them by means like a gun safe if the patient has them). They also have to be things that the patient is willing and able to do, and ideally at least some strategies that they know have worked in the past. Here’s a pretty good, basic guide: https://sprc.org/wp-content/uploads/2023/01/SafetyPlanningGuide-Quick-Guide-for-Clinicians.pdf

 

[Ollie123]

I have nothing useful to contribute, but did have one practicum site back in graduate school that had apparently been using these for years with the header "Suicide Contract" until I pointed out that: A) There was mixed evidence regarding their efficacy (....I was a trainee trying to be delicate?) and B) If they wanted to continue they should at least consider renaming them to a "No Suicide Contract" or something like that. Though creating a death pact with your therapist is pretty hardcore.

They opted for the latter.

 

[Sanman]

I have nothing useful to contribute, but did have one practicum site back in graduate school that had apparently been using these for years with the header "Suicide Contract" until I pointed out that: A) There was mixed evidence regarding their efficacy (....I was a trainee trying to be delicate?) and B) If they wanted to continue they should at least consider renaming them to a "No Suicide Contract" or something like that. Though creating a death pact with your therapist is pretty hardcore.

They opted for the latter.

Can someone that does research for a living please complete an analysis on whether suicide contracts are more or less efficacious than abstinence pledges? I think it would make for some great bedtime reading.

 

[Therapist4Chnge]

Yeah, that’s always been my understanding—that they offer no meaningful clinical or legal value to either the clinician or patient. That’s why it baffles me that they are still so common, and a lot of programs are still training trainees to use them.

It's easily been 15 years that we've known that contracting can be seen as coercive and it can provide a false sense of security to the facility. I don't know the current case law on it, but I suspect it'd be an uphill battle. I've seen safety planning utilize many of the same aspects from contracting, but then again...that's really just standard of care, and the contracting is the part that would get mixed support (at best). I made sure they weren't used at any hospital I worked at (after training at least). "Contracting" for opioids in the VA system has a similar feel, but that was a battle I had no shot of winning as a trainee.

 

[Therapist4Chnge]

Safety plans are definitely used outside of DBT contexts. They involve making a detailed step by step plan with the patient of strategies they can use to cope with SI. They typically include things like basic coping at the lower levels (read, take a walk, listen to peaceful music, meditate, etc) to reaching out to reliable social supports to reaching out to reliable social supports about suicidality to calling crisis hotlines to reaching out to providers to going to the hospital. They need to be detailed (list specific names and phone numbers), have backup options (who do they call if Person A doesn’t pick up, etc), and have to be readily physically or electronically accessible (some people suggest putting them by means like a gun safe if the patient has them). They also have to be things that the patient is willing and able to do, and ideally at least some strategies that they know have worked in the past. Here’s a pretty good, basic guide: https://sprc.org/wp-content/uploads/2023/01/SafetyPlanningGuide-Quick-Guide-for-Clinicians.pdf

This is gold.

Back when I utilized safety plans, we'd usually do 3 tiers of responses, in line with your recs. Lowest tier include distractions/activities, next tier was reaching out to specific people (w names and numbers), and the third tier was PCP/ED/911. The details, especially having everything readily available when they start feeling overwhelmed, is crucial. Being able to make the process collaborative can assist with buy-in and improve compliance. We'd walk through scenarios and talk through their thinking, to suss out any concerns they might have. As clinicians, we know that if someone truly wants to unalive themselves, they will find a way. It is our job to help that person the best we can and put them in the best realistic position to not escalate to behaviors that cannot be taken back.

 

[futureapppsy2]

I have nothing useful to contribute, but did have one practicum site back in graduate school that had apparently been using these for years with the header "Suicide Contract" until I pointed out that: A) There was mixed evidence regarding their efficacy (....I was a trainee trying to be delicate?) and B) If they wanted to continue they should at least consider renaming them to a "No Suicide Contract" or something like that. Though creating a death pact with your therapist is pretty hardcore.

They opted for the latter.

That would be a great plot for Criminal Minds, ngl!

 

[AcronymAllergy]

Use of suicide safety plans is one thing that I feel VA generally did/does right (assuming the providers take the time to fill them out correctly). Their template is surprisingly helpful and efficient. The only downside was that the printed version of the template, which I'd give a couple copies of to the patient when we were discussing where they'd keep it, wasn't always the most attractive or easy to read document; however, that's a function of the limitations of CPRS.

 

[BuckeyeLove]

This (amongst a million other things) is why i hope to only ever work FT doing inpatient work (until i retire and just do evals).

 

[LM02]

Great article on this topic:

Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial - PubMed

Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.

pubmed.ncbi.nlm.nih.gov

Also to add that crisis response planning is similar (though not identical) to safety planning.

 

[albatross_at_crossroads]

DBT requires that the patient take suicide off of the table for the duration of the treatment. If the patient repeatedly engages in suicidal or parasuicidal behavior, they would eventually be "unilaterally discharged."

It's not quite the same as a no suicide/harm contract, though.

That was my understanding too. I think the person describing this to us (trainees) kept referring to it as a "contract", but it seems to be something different.

Safety plans are definitely used outside of DBT contexts. They involve making a detailed step by step plan with the patient of strategies they can use to cope with SI. They typically include things like basic coping at the lower levels (read, take a walk, listen to peaceful music, meditate, etc) to reaching out to reliable social supports to reaching out to reliable social supports about suicidality to calling crisis hotlines to reaching out to providers to going to the hospital. They need to be detailed (list specific names and phone numbers), have backup options (who do they call if Person A doesn’t pick up, etc), and have to be readily physically or electronically accessible (some people suggest putting them by means like a gun safe if the patient has them). They also have to be things that the patient is willing and able to do, and ideally at least some strategies that they know have worked in the past. Here’s a pretty good, basic guide: https://sprc.org/wp-content/uploads/2023/01/SafetyPlanningGuide-Quick-Guide-for-Clinicians.pdf

Thank you very much! This list of strategies is very helpful and the resource clear and easy to use.

I think I don't have a good sense of what these contracts entail. In my training (in Canada) nobody ever mentioned them as such, we only discussed SI assessment and safety planning. Other than having a paper to protect your behind, I don't really see the usefulness of just having the client/patient "pinky-promise" they won't kill themselves.

 

[cara susanna]

That was my understanding too. I think the person describing this to us (trainees) kept referring to it as a "contract", but it seems to be something different.


Thank you very much! This list of strategies is very helpful and the resource clear and easy to use.

I think I don't have a good sense of what these contracts entail. In my training (in Canada) nobody ever mentioned them as such, we only discussed SI assessment and safety planning. Other than having a paper to protect your behind, I don't really see the usefulness of just having the client/patient "pinky-promise" they won't kill themselves.

There is a contract patients sign in DBT that includes the above stipulation (as well as others), but it's a treatment contract, not a suicide contract. Part of DBT is getting the patient to commit to the treatment, so they sign the treatment contract to signal their commitment. We review this every so often (I usually do 6 months) or as needed. If a patient is constantly continuing to engage in suicidal or preparatory behavior, that would be seen as not being committed to the treatment, in which case it will not work.

 

[smalltownpsych]

I work with highly suicidal patients all the time. My patients are the kind that get discharged from DBT programs. My training in risk management is to document risk assessment and document plans to mitigate the risk. My number one go to is to increase contact with myself. Here is my number, call me if you need to, i want to see you tomorrow to see how you’re doing. Next step is to engage others in support whether family or paid depends on the patient. Next is a 24 hour staffed crisis center and/or hospital. I also find that the more seriously you take it the better. Patients and others want to minimize, our job is to do the opposite. Also, I put it on the patient to reassure me that they don’t need to be inpatient and to make that choice of it is what they need to do. The only contract that I do with patients is a verbal agreement with me and it is not to to not kill themselves so much as it is to agree to some of the plans and give me a chance to help them through it.

 

[smalltownpsych]

Also, without rapport no plan will help. Our number one tool in this type of situation is to build a connection to someone when no one else can. If I can’t build rapport, then they are getting locked up until someone can. Almost always the super high risk patient agrees with that since at this point they don’t give an f anyway. We waste a lot of time locking up people against their will that don’t need it in my mind which is part of what makes it worse, hence why real DBT has so much built into it to address the underlying causes and not reinforce the suicidal practicing.

 

[smalltownpsych]

One more thing. It is good to argue with them about being locked up because they will have to state reasons why they want to live and it is good CBT strategy to have the patient challenge themselves that their hopeless beliefs are irrational.

 

[borne_before]

One more thing. It is good to argue with them about being locked up because they will have to state reasons why they want to live and it is good CBT strategy to have the patient challenge themselves that their hopeless beliefs are irrational.

That's kind of irreverant, right?

I love telling patients that their suicidality is rational - like "your brain is just trying to solve a problem and it's like "oh I know... I wouldn't feel bad if I was dead."

 

[Sanman]

That's kind of irreverant, right?

I love telling patients that their suicidality is rational - like "your brain is just trying to solve a problem and it's like "oh I know... I wouldn't feel bad if I was dead."

Sometimes it is. Having worked with quadraplegic and functional quadraplegic patients with ALS, there is no better solution given the lack of treatment and the same outcome. Had a mentor that went through the same thing in the 80s with AIDS patients when there was no treatment. Not what you meant, but it is a pet peeve of mine with all the rhetoric around stopping suicide. Especially in a country that will happily leave a 90 year old homeless, but I digress.

 

[cara susanna]

That's kind of irreverant, right?

I love telling patients that their suicidality is rational - like "your brain is just trying to solve a problem and it's like "oh I know... I wouldn't feel bad if I was dead."

That is incredibly irreverent, lol. That is straight out of the DBT handbook.

 

[R. Matey]

"your brain is just trying to solve a problem and it's like "oh I know... I wouldn't feel bad if I was dead."

A. Beck couldn't have said it better himself.

 

[smalltownpsych]

The hopelessness is what is often tied to irrational core beliefs not the thoughts of suicide. I actually normalize the suicidal thoughts and connect it to the level of distress they are experiencing.

 

[smalltownpsych]

That's kind of irreverant, right?

I love telling patients that their suicidality is rational - like "your brain is just trying to solve a problem and it's like "oh I know... I wouldn't feel bad if I was dead."

I’m not sure what the irreverent part is. I think the point I was making is that if a patient does not want to be in a psych hospital it is because they want to do something else and often a desire to do things is a desire to live. When a patient doesn’t care about it, that’s when they are at higher risk.

 

[chicandtoughness]

I do use suicide contracts, but as a method for helping the patient self regulate in the moment. If they're flustered and overwhelmed and feel absolutely hopeless and helpless, I do think it is grounding to say "It's okay, let's just focus here on listing 3 clear skills you can use in the moment... get out your phone and let's pick 3 people to star as your favorites so you have easy access to call them... talk me through 3 safe places you can retreat to in your house...." etc. For someone who can't verbally process in the moment, going back to the simple basics, with an external focus (e.g. "stare at this sheet in front of you and gather attention there"), can be wildly helpful.

tl;dr it's not the content of the sheet that matters, it's the process. I certainly don't just make them sign a sheet that says "I agree to contract for safety" lmao. And obviously if they're in imminent risk I'm transporting them to inpatient not having them sign a paper and sending them home.

 

[futureapppsy2]

I do use suicide contracts, but as a method for helping the patient self regulate in the moment. If they're flustered and overwhelmed and feel absolutely hopeless and helpless, I do think it is grounding to say "It's okay, let's just focus here on listing 3 clear skills you can use in the moment... get out your phone and let's pick 3 people to star as your favorites so you have easy access to call them... talk me through 3 safe places you can retreat to in your house...." etc. For someone who can't verbally process in the moment, going back to the simple basics, with an external focus (e.g. "stare at this sheet in front of you and gather attention there"), can be wildly helpful.

tl;dr it's not the content of the sheet that matters, it's the process. I certainly don't just make them sign a sheet that says "I agree to contract for safety" lmao. And obviously if they're in imminent risk I'm transporting them to inpatient not having them sign a paper and sending them home.

That's the difference between a no-suicide contract and a safety plan, IMO.

 

[chicandtoughness]

That's the difference between a no-suicide contract and a safety plan, IMO.

I was a little surprised to see this thread tbh because these two have always been one and the same in my mind 😅

 

[msc545]

Bit of a rant, but it’s been known for years that making a suicide person promise that they won’t hurt/kill themself doesn’t generally result in any sort of effective suicidal prevention, especially if there’s no or a very minimal safety planning attached to that contract (I’ve seen one case where the sole safety plan attached was “call someone” and another was “call a doctor”—no contact information for easy access, not even a specific name, no alternative for what the patient should do if said person didn’t pick up, etc), but people will not stop these in favor of actual safety planning. Is there actual liability protection in doing these anywhere in the US? Or does it just relieve clinician distress?

These things have no value at all, but a lot of clinicians need to feel that they have "done something." In truth doing this is doing effectively nothing and it may do actual harm by inducing complacency.

 

[msc545]

DBT requires that the patient take suicide off of the table for the duration of the treatment. If the patient repeatedly engages in suicidal or parasuicidal behavior, they would eventually be "unilaterally discharged."

It's not quite the same as a no suicide/harm contract, though.

They unilaterally discharge borderlines? Strikes me as a great way to incur a lot of liability and malpractice problems.

 

[cara susanna]

They unilaterally discharge borderlines? Strikes me as a great way to incur a lot of liability and malpractice problems.

They discharge them from DBT. I'm sure they offer referrals to non-DBT therapists or programs. But if they aren't actually engaging in or committed to DBT, it isn't gonna work so it's 1) a waste of time 2) the patient will think "but I'm doing DBT and it's not working!" and thus conclude DBT doesn't work when, in fact, they are not actually doing DBT.