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

Posted on March 12, 2008
Filed Under Psychology (PsyD, PhD)

by Tim Shea, M.S.
SDN Staff Writer

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

 

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.

Comments

5 Responses to “Sign on the Dotted Line: No-Harm Contracts in the Clinical Setting”

  1. Therapist4Chnge on March 12th, 2008 7:20 am

    Here is a discussion on the topic: http://forums.studentdoctor.net/showthread.php?t=504057

  2. Solideliquid on March 13th, 2008 2:50 pm

    From speaking with our legal dept, this document provides very little in the form of legal protection in the event of a bad outcome.

  3. Therapist4Chnge on March 13th, 2008 9:56 pm

    The use really isn’t to shield the hospital, it is for the patient’s safety, though some people incorrectly assume it can be used as a legal defense.

  4. MiraCheskis on March 14th, 2008 10:12 am

    …but does it _really_ work? Does it really reduce the self-harming behavior? Are there any studies being done? Do we have any solid numbers, here?

  5. Therapist4Chnge on April 3rd, 2008 12:15 pm

    Mira,

    In the right setting and circumstances it has shown to be effective, though many people try and use it in every situation, and it is not generalizable in all situations. I’m currently putting together a larger evaluation of the current literature, so I’ll post more finding later this year as a follow-up.

    (Sorry for not replying sooner, I just happened to see this today)

    -Tim

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