From the Guidelines
Suicide safety contracts are not recommended as a standalone intervention for managing patients at risk of suicide. These contracts (also called "no-harm contracts" or "no-suicide agreements") involve patients promising not to harm themselves and to contact help if suicidal thoughts occur. Despite their historical popularity, research has consistently shown that these contracts have no empirical evidence supporting their effectiveness in preventing suicide attempts or deaths 1. Instead, comprehensive suicide risk assessment and management should include thorough evaluation of risk factors, protective factors, and warning signs; development of a collaborative safety plan that identifies triggers, coping strategies, social supports, and means restriction; appropriate level of care determination; and ongoing monitoring.
Key Components of Suicide Risk Assessment and Management
- Thorough evaluation of risk factors, protective factors, and warning signs
- Development of a collaborative safety plan
- Appropriate level of care determination
- Ongoing monitoring Safety planning, unlike contracting, actively engages patients in identifying personal warning signs and developing specific coping strategies. The ineffectiveness of suicide contracts likely stems from their focus on extracting a promise rather than building skills and support systems. Additionally, they may create a false sense of security for clinicians while potentially damaging therapeutic relationships if patients perceive them as coercive or primarily designed to protect the provider from liability.
Alternative Strategies
- Means restriction counseling, which includes suggestions for securing knives, locking up medicines, and removing firearms 1
- Restricting access to potentially lethal means, including access to such means in the homes of friends or family 1
- Temporarily relocating firearms to a safe location, such as with a relative or friend, until the patient is in a better emotional state 1 The most recent and highest quality study, a meta-analysis published in 2021, found that safety planning-type interventions are effective in reducing suicidal behavior, but notes that individual trials on the effectiveness of these interventions have yielded conflicting results 1. Therefore, a comprehensive approach to suicide risk assessment and management, including safety planning and means restriction counseling, is recommended.
From the Research
Role of Suicide Safety Contract
- A suicide safety contract is a procedure used in the management of suicidal patients, with significant patient care, risk management, and medicolegal implications 2.
- The contract for safety is a verbal or written agreement intended to forestall suicidal behavior, and its use has been part of suicide prevention protocols since the second half of the 20th century 3.
Effectiveness of Suicide Safety Contracts
- Empirically based evidence to support the use of the contract for safety in any population is very limited, particularly in adolescent populations 2.
- Some studies suggest that suicide safety planning interventions, which may include contracts, can be effective in reducing suicidal behavior and ideation 4, 5.
- However, the use of contracts should be considered with caution, and only in patients who are deemed capable of giving informed consent 2, 6.
Clinical Considerations
- A contract should never replace a thorough assessment of a patient's suicide risk factors 2.
- Contracting for safety requires delicate discretion, and its use should be judiciously considered in clinical practice 3, 6.
- The establishment of contracts in clinical use and their indications should be carefully described, including special issues like suicidality in adolescence 3.
Implications for Practice
- Occupational therapists and other healthcare providers should be aware of the potential benefits and limitations of suicide safety contracts in managing patients at risk of suicide 5.
- The use of contracts should be considered as part of a comprehensive approach to suicide prevention, including evidence-based strategies to reduce suicidal behavior 4, 5.