One of my colleagues angrily shared a story about a friend of hers. The friend’s father had been despondent ever since his wife died a few months ago. He told his daughter that it would be better if he just ended it all and joined his wife.
The daughter was sufficiently alarmed to take him to the local emergency room. There, he was interviewed and asked to sign a Contract for Safety, promising that he wouldn’t harm himself. He sighed. He signed. And he was sent home.
His daughter was beside herself: “Of course he signed the thing’, she told my colleague. “He knew if he refused he’d be admitted and he didn’t want to give up the option. So what was I supposed to do?”
Fortunately, this story has a positive ending. The daughter was able to persuade her father to go to a therapist. The therapist was experienced and kind and, possibly because he was about the same age, able to connect with a 70-year-old depressed man who was grieving. But the story is a good illustration of the limitations of the often used Contract for Safety.
What’s Wrong with a Contract for Safety?
Results of Contracts for Safety (CFS), where a client is asked to agree either verbally or in writing that she will not engage in self harm, were first published by Drye, et.al. in 1973 . Although these original authors only investigated its effectiveness with patients in a long term relationship with their therapist, the use of the tool has since become standard practice for many crisis teams and clinicians, even during an initial interview. But are they effective?
A careful review of the literature by Kelly and Knudson at Idaho State University’s Institute of Rural Health in 2000 showed that no studies demonstrate that contracts are an effective way to prevent suicide .
A 2001 study by B.L. Drew found that of people who attempted suicide in a psychiatric hospital, 65% had signed a CFS . In still another study, this one a 2000 survey of psychiatrists in Minnesota by Dr. Jerome Kroll, 40% had a patient make a serious or successful suicide attempt after signing a CFS.
Contracts for Safety have not been found to be useful with suicidal patients who are psychotic, impulsive, depressed or agitated, who have a personality disorder or who are under the influence of alcohol or street drugs – the very patients who are the most likely to show up in emergency rooms.
In fact, there is even some evidence that for people diagnosed with Borderline Personality Disorder, a CFS may make things worse.
There are a number of reasons why clinicians continue to use Contracts for Safety, despite the evidence that when used alone, they may not be helpful and, in some cases, may even be harmful.
First, most clinicians receive limited training in suicidality. The use of the Contract for Safety has become almost folkloric. Confronted with a suicidal client, the clinician may have heard that such a contract is helpful. Doing something, even something that may be ineffective, feels better than doing nothing.
Secondly, some clinicians seem to think that the use and documentation of a CFS protects them from legal liability if the client does commit suicide
Studies have shown, however, that having a CFS does not decrease a clinician’s liability. Thirdly, some clinicians think they can relax a bit if they have a contract. They mistakenly believe that having the contract buys them some time to help the client abandon suicide as a solution to his problems.
Finally, a severely mentally ill or intellectually disabled or addicted client may be in no shape to make a “contract” that represents an informed, responsible decision.
If Not a Contract for Safety, What?
Obtain training: There are other, more effective responses to the threat of suicide than the Contract for Safety. But in order for any of them to be maximally effective, the clinician must develop his or her own expertise. (See related article). Few graduate and professional programs offer adequate training to new clinicians. If you are among those who never received such training, it’s essential to fill in that gap.
Develop the therapeutic relationship: Limit use of a Contract for Safety to clients with whom you have a long-term solid relationship: In such cases, the contract can be a useful way to open a conversation about their intentions and feelings.
It can be a relief to a long term client that you are taking her despair seriously and that you care enough to explore whether such an agreement would be helpful. When the client is in crisis, consider increasing the frequency of sessions or other types of contact.
Use the contract only as a part of a full risk assessment: A comprehensive risk assessment includes an evaluation of risk factors, an understanding of what has precipitated suicidal thinking, assessment of the individual’s plan and access to means, investigation of any history of past attempts and identification of resiliency factors and potential supports.
Assess regularly: Risk assessment is a dynamic process and should be done regularly with clients who present with or have a history of suicidality or self-harm.
Take time to review risk whenever there is a change in presentation, if symptoms persist or get worse, if medications are changed or if the client talks about terminating.
Periodically utilize a tool like the Beck Depression Scale to check for progress with depressed clients. Regularly do a Mental Status Exam. Be sure to assess the client for delusions, hallucinations, a thought disorder or a decrease in capacity for reality testing.
Develop a Safety Plan with your client. A Safety Plan differs from a Contract for Safety in several important ways. Such a plan focuses on what the client will do to keep himself safe rather than what he won’t do to harm himself.
- Help the client identify her own triggers and situations that put her at greatest risk.
- Work with the client to list and practice whatever coping skills he has available.
- Determine if the client has access to guns, potentially lethal medications or any other means for hurting herself. Ask/insist that the client give such items to a trusted friend or relative.
- Ask the client to permit you to contact family members or other trusted individuals who can be helpful in getting her through a crisis. If possible, involve those individuals in some of the client’s sessions to clarify whether they are willing to accept a supportive role and what they can do that is the most helpful for this individual. For example: Do they just need to talk the person through on the phone or do they need to take the person to the hospital?
- Identify other sources of support such as the local crisis team, the National Suicide Prevention Lifeline or the local NAMI group. Write down the phone numbers and ask the client to keep them with him.
- Collaborate. If a client becomes suicidal, get a release to talk to the prescriber and to collaborate with the local crisis team. With the client’s permission, involve the family (see above). Increase your own supervision.
The Contract for Safety has become too much a part of the routine for clinicians when confronted with the suicidal client.
Although it was created as an assessment tool for use with clients who have a relationship with their therapist, it is too often the immediate and only response to suicidality. Clinical decisions regarding risk require a much more thorough and complex assessment of the individual. When there is clinical concern about the client’s safety, it is a safety plan, not a contract, that is most likely to result in positive outcomes.
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