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NO-SUICIDE CONTRACTS: AN OVERVIEWAND RECOMMENDATIONS

????????????????????????????????????????????????????

LILLIAN M. RANGE, CATHERINE CAMPBELL, STACEY H. KOVAC,

MICHELLE MARION-JONES, HOLLYALDRIDGE, STEPHEN KOGOS,

AND YOLANDA CRUMP

The University of Southern Mississippi, Hattiesburg, Mississipi

No-suicide contracts, in their various forms, can deepen commitment to a positive action,

strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assess-

ment, and document precautions. Conversely, they can angeror inhibit the client, introduce

coercion into therapy, be used disingenuously, and induce false security in the clinician.Research on no-suicide contracts (frequency surveys, assessments of behavior after con-

tracting, and opinions of users) has limitations common to naturalistic studies, and is

now ready for more rigorous methods. Mental health professions should be trained to deal

with suicidal individuals, including how to use no-suicide contracts. Good contracts are

specific, individualized, collaborative, positive, context-sensitive, and copied. However,

they are not a thorough assessment, a guarantee against legal liability, nor a substitute for

a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute forsound

clinical judgment.

A contract is an agreement between two or more people (Neufeldt &

Sparks,1990). Psychologists often use contracts as one aspect of treatment

for a variety of problems and disorders. One form of mental=behavioralhealth contracting is a no-suicide contract. Although somewhat contro-

versial, no-suicide contracts are widely used by mental health profes-sionals (Stanford, Goetz, & Bloom, 1994). The following article will

describe various forms of no-suicide contracts, delineate the advantages

and disadvantages of using no-suicide contracts in therapy, examine

Received11 August 2000; accepted 30 November 2000.

Portions of this paper were presented at a symposium at the annual meeting of the Mississippi

Psychological Association, October,1999, Biloxi, MS.

Address correspondence to Lillian M. Range, Department of Psychology, The University of

Southern Mississippi, Hattiesburg, MS 39406-5025. E-mail: [email protected].

51

Death Studies, 26: 51774, 2002

Copyright# 2002 Brunner-Routledg e

0748-1187/02 $12.00 + .00


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empirical research on no-suicide contracts, and make research, training,

and clinical recommendations.

Description

A no-suicide contract (also called a no-harm contract, life-maintenance

agreement, or commitment for safety) entails an explicit statement of no

harm and a specific time frame. The time frame is typically as short as a

few hours or as long as a few days, until the next therapy or crisis inter-

vention session. The no-suicide contract also contains contingencies incase the client becomes unable to keep the agreement. Typically, both

client and therapist keep a copy. In general, no-suicide contracts, like

all behavioral contracts, involve negotiating terms in order to form an

agreement or contract. Both the therapist and client should be accoun-

table for the terms.

The wording of no-suicide contracts varies with individual clients. For

example, no-suicide contracts for adults are typically longer and morecomplex than those for children. (See Appendix A for a contract for

adults used at the University of Southern Mississippis Counseling Cen-

ter.) The contract includes up to three individual preferences of action if

clients feel that they may harm themselves or others. Also, the contract

asks clients to agree to admit themselves to the emergency room as an-

other plan of action. This example illustrates the way a contract is cur-

rently used.Like other behavioral contracts, no-suicide contracts for children

should be developmentally appropriate. An age-based contract usesage-appropriate language and simplified statements regarding options

for assistance. The format varies slightly between the age groups, but

the fundamental principles throughout are that the childs goal is to live

and become happier, that there are people available if the child believes

that s=he may harm herself=himself or others, and that the counseloragrees to assist in any way possible. The contract reminds children that

despite their feelings of helplessness, they can seek assistance from a car-

ing and responsible adult. A theme throughout the contracts is empow-

ering children to help themselves. One example of empowerment is to

ask the child to complete the spaces on whom to contact in time of need

(Davidson & Range, 2000). Appendices B, C, and D contain examples of

contracts for children at various ages.

52 L. M. Range et al.


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Another option for children is the school-based contract (see Appen-

dix E). General enough to be used in elementary through high school,

this contract identifies the child as a student of the particular school

and provides a name and phone number of the school counselor. Thisagreement also encourages the student to contact a crisis hotline if the

counselor is unavailable (Poland,1989).The 24-hour hotline can guaran-

tee that the child will be able to reach a concerned adult even if parents

and peers are unavailable.

Clinicians should not feel constrained by the use of a `conventional

agreement if it does not seem appropriate for the particular client. One

option that is often used is for the client and clinician to collaborate on apersonalized no-suicide agreement. The negotiation process, as well as

the personal nature of the agreement, can provide a feeling of accom-

plishment and self-fulfillment for the client, as well as a visual plan that

is tailored to the clients personal issues.

Advantages and Disadvantages in Therapy

No-suicide contracts can have advantages that could be classified in be-

havioral, interpersonal, intrapersonal, assessment, and administrative

terms. Likewise, they can have disadvantages that could be classified in

the same way.

Advantages

Behaviorally, no-suicide contracts help the client commit to a course ofaction that is inconsistent with suicide (Brent, 1997). Because suicidal

ideation is often impulsive, a contract may provide the immediate con-

trol that clients need (McBrien,1983). Further, no-suicide contracts can

establish contingencies for specific behaviors (McLean & Taylor, 1994).

In the formulation of the no-suicide contract, the client and therapistoften review what specific steps the client would take if the same difficul-

ties that led to the suicidal crisis would resurface, and make alternative

coping plans (Brent,1997). Hence, no-suicide contracts behaviorally help

clients commit to positive action.

Interpersonally, no-suicide contracts can help to initiate and establish

a therapeutic alliance (Drew,1999; Stanford et al.,1994), and can under-

score the realistic need for the patients active collaboration in treatment

53No-Suicide Contracts


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(Miller, 1990). Clients who are at risk for suicide may believe that the

therapist who asks them to sign a no-suicide contract is genuinely con-

cerned about their safety. Thus, the no-suicide agreement may help cli-

ents view the therapist as empathic (Miller, 1999). Establishing acommon goal may be useful in strengthening the relationship between

the therapist and client, which, in turn, may lead to positive outcomes in

therapy (Sills,1997).

Also, the no-suicide contract can help both client and therapist estab-

lish short-term goals that are attainable. For example, the client who

calls the crisis hotline five times during one week could set a goal of call-

ing only once during the following week.Thus, the no-suicide agreementcan help the suicidal patient postpone suicide until after a crisis has

passed. After coping successfully with the crisis, the client may realize

that suicide is not the only option.

Further, no-suicide contracts may also open up communication be-

tween the client and therapist on an issue that is viewed by many as

taboo. Making a specific agreement could help clients feel comfortable

in describing their own urges and intentions in regards to suicide. Also,after negotiating a no-suicide contract, clients may feel a sense of reliefthat the therapist brought up the issue of suicide and may feel more com-

fortable working on other issues in therapy as well (Rudestam,1986). De-

veloping a specific no-suicide agreement could open the doors to deeper

communication than previously occurred in therapy.

Intrapersonally, no-suicide contracts may also reduce both clients

and therapists anxiety. Clients who use a no-suicide contract may feelin control of their suicidal thoughts and behaviors because they set their

own terms. This feeling of control with suicidal thoughts may extend

further as clients take responsibility for their treatment in therapy

(Miller, 1999). Showing empathy and genuine concern for the client

may help them with their suicidal thoughts and feelings, and an actual

contract can symbolize in a concrete way this concern and this ongoing

relationship with the therapist. Therapists who use a no-suicide contractmay find that it helps to reduce therapist anxiety as well (Stanford et al.,

1994). Thus, no-suicide contracts may increase client autonomy, symbo-

lize therapist concern, and decrease anxiety for both.

An assessment advantage of no-suicide contracts is that they can be

used to evaluate suicide risk. Reluctance to sign a no-suicide contract

may raise a ` red flag for the therapist. A client who is unable to sign a

no-suicide contract may need to be hospitalized. Indeed, no-suicide



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contracts were first reported as a quick assessment method (Drye,

Goulding, & Goulding, 1973), and clinicians recommend their use as an

exquisitely sensitive assessment tool (Shea,1999). Patients who seem con-

fident about the agreement, maintain eye contact, and show no hesi-tancy, qualifications, or other signs of ambivalence or deceit are at low

suicide risk (Shea,1999); however, patients who object or make qualifica-

tions are at relatively higher suicide risk (Drye et al.,1973). Inasmuch as

no-suicide contracts involve active discussion with the client, they could

be more useful in assessing suicidal risk than objective paper-and-pencil

inventories that allow for no interactive communication (Rudestam,

1986). No-suicide contracts may allow the therapist to assess suicidal riskin a way that is different from objective suicide inventories.

An administrative advantage of no-suicide contracts is to serve as

partial documentation of the therapists efforts to contain suicide risk,

and are more compelling than a global statement in a therapy note.

Although there are no guarantees against lawsuits, the best course is ` to

provide good care, make the best decisions possible, and document these

activities to the best of ones ability (Clark, 1998, p. 92). A no-suicidecontract could be part of this documentation.

Disadvantages

No-suicide contracts have disadvantages that parallel their advantages.

A therapeutic disadvantage is that clients may mistakenly believe that

the therapists only concern is the contract or the potential for legalaction, rather than any genuine regard for the client. In this case, cli-

ents could view the no-suicide contract as a coping mechanism for thetherapist rather than as a clinical intervention tool for the client

(Miller, 1999). Having the no-suicide contract in a standardized,

inflexible form could reinforce this view. Thus, no-suicide contracts

could lead clients to doubt the therapists concern for them. This

doubt, whether reasonable or unreasonable, could interfere with thetherapeutic alliance.

Additionally, clients who are reluctant to change their behavior, even

if it is self-destructive, may become angry when the therapist asks them

to sign a no-suicide contract. The anger could create a chance for the

therapist and the client to discuss openly the clients anger but could also

increase distance between client and therapist and reduce the therapeu-

tic alliance. Further, asking for a no-suicide contract could even set the



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stage for counterproductive manipulation and theatrical standoffs

(Shea, 1999). Thus, no-suicide contracts could be seen as intrusive and

therefore weaken the relationship between the therapist and the client.

Further, no-suicide contracts may also inhibit clients from discussingtheir suicidal thoughts with the therapist. Clients could believe that dis-

cussing their suicidal ideations violates the terms of the no-suicide con-

tract (Miller,1999). In addition, clients may feel that they are a failure if

they continue to have suicidal thoughts. So, instead of disclosing these

thoughts to the therapist, clients keep the thoughts to themselves, becom-

ing increasingly isolated and despondent. In this case, the therapist may

mistakenly believe that the client is no longer suicidal (Miller, 1999), apotentially dangerous situation.

Also, no-suicide contracts could introduce an element of coercion into

the therapeutic relationship (Miller, 1990). Clients may feel that they

must complete the no-suicide contract in order to continue receiving ser-

vices from the therapist. This perception could create a power differen-

tial between the therapist and the client that interferes with therapy.

Indeed, some experts posit that the threat of suicide makes a true thera-peutic contract impossible because the central feature of that contract,the element of patient choice, may be restricted or removed (Miller,

1999).

A final therapeutic disadvantage is that the therapist might actually

focus on the contract to the detriment of the therapeutic relationship.

The no-suicide contract alone is a shallow substitute for complex, em-

pathic interpersonal involvement (Miller,1990). If the therapist confinesthe largest portion of therapy with a suicidal patient to obtaining a no-

suicide contract, other aspects of the communication could be negatively

affected (Miller, 1999). Further, persons lacking adequate training may

over-rely on no-suicide contracts or use them disingenuously. For exam-

ple, an aide with little or no connection to the suicidal person could ask

for a signature on a preprinted form, but this procedure may have little

or no impact on the persons future behavior. In addition, if no-suicidecontracts reduce the therapists level of anxiety, the therapist could

develop a false sense of security (Callahan,1996). From the clients point

of view or the therapists point of view, no-suicide contracts might actu-

ally interfere with therapy.

An assessment disadvantage of no-suicide contracts is that they may

mistakenly convey the idea to clinicians that they have assessed suicidal-

ity. No-suicide contracts are static and easily broken and have no



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predictive validity (Berman & Jobes, 1994). A no-suicide contract is no

substitute for thorough assessment.

An administrative disadvantage of no-suicide contracts is that they

may mistakenly convey the idea to clinicians that they are protected incase of a malpractice lawsuit. No-suicide contracts are not legal docu-

ments; they are not legally binding (Miller, 1999; Stanford et al., 1994).

No-suicide contracts cannot be solely used in a court of law to demon-

strate adequate assessment or management of suicidal risk (Drew,1999;

Miller, 1999). Therapists must decide how they are going to handle a si-

tuation if a client refuses to complete a no-suicide contract, a scenario

that is likely to occur at some point in a therapists career. Even if a per-son refuses to sign a no-suicide contract, the therapist must protect him

or her from self-injury. Therefore, from a legal perspective, the no-

suicide contract may not be useful because the therapist has a legal obli-

gation to ensure the clients safety.

No suicide contracts may have advantages or disadvantages depend-

ing on the client, the therapist, and their relationship. Although having a

person sign a contract may be helpful, it could be that those who aremost helped by the contract are also those who are most helped by em-pathy, the chance to ventilate their problems, or the practical advice that

the therapist gives during the crisis. No-suicide contracts are no substi-

tute for good clinical judgment.

Empirical Research

Although no-suicide contracts are frequently cited in psychological, psy-chiatric, and nursing literature, research on these contracts is sparse.

One reason for this lack of research is that suicide is a low base-rate phe-

nomenon, so interventions to prevent it are hard to prove or disprove

(Mishara & Daigle, 1997). The majority of suicidal patients, even those

who are highly suicidal, do not commit suicide. Another reason is thatthe most experimentally sound research design would be to identify a

large group of suicidal individuals, obtain a no-suicide contract with a

randomly selected half of them, and measure the suicide rate in the

whole group. To date, this type of design has not been conducted.There-

fore, no-suicide agreements are generally recommended by many sui-

cide experts but are rarely studied empirically. Indeed, their use is

based more on impressions than data (Miller, 1999). The research that



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does exist falls into three general categories: frequency surveys, research

on the impact of no-suicide contracts on suicidal behavior, and opinions

of users.

Frequency Surveys

In the original publication, Drye et al. (1973) reported training clinicians

to make no-suicide contracts, estimating that they made 600 no-suicide

contracts over five years. They surveyed 31 trainees, who reported using

no-suicide agreements with 609 suicidal patients, 266 of whom were

` seriously suicidal (Drye et al., 1973). This original work indicated thatclinicians used no-suicide contracts after training but did not assess

whether they used no-suicide contracts before training.

More recent and more systematic surveys indicate that most mental

health professionals use no-suicide contracts. A survey of 84 directors of

psychiatric hospitals and units (82% response rate) defined suicidal be-

havior as deliberate self-harm with suicidal intent. The survey did not

limit suicidal behavior on the basis of lethality, but excluded self-mutilat-ing behavior that had purposes other than death (e.g., to relieve anxiety,

or seek attention). The majority of these administrators (n = 66, 79%)

reported using no-suicide contracts, which were typically given by

nurses and typically used with patients who talked, threatened, or at-

tempted suicide. These directors used a variety of types of no-suicide

contracts, including handwritten (n = 48, 74%), verbal (n = 47, 72%),

and preprinted forms (n =10, 15%) (Drew, 1999). Thus, administratorsreport that no-suicide contracts are a common professional experience.

Head nurses report the same frequency of use. In a survey of headnurses of psychiatric inpatient units, more than 80% said that their units

used no-suicide contracts. Further, these head nurses thought these con-

tracts were useful (Green & Grindel,1996). Administrators of psychiatric

hospitals, and head nurses agree that no-suicide contracts are common.

This experience comes early in a mental health career. In one surveyof 112 clinicians, by the completion of residency or internship, 79% of

psychiatrists and 72% of psychologists at Harvard Medical School re-

ported that they had witnessed the use of no-suicide contracts. Addition-

ally,77% of the psychiatrists and 75% of the psychologists stated that the

contracts were recommended at their place of employment; 86% of psy-

chiatrists and 71% of the psychologists regularly used them; and 61% of

the psychiatrists and 71% of the psychologists used them at least half of



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the time with suicidal individuals. Also, 61% of psychiatrists and 71% of

psychologists reported no formal training, which was defined as one or

more lectures focusing on the history and use of no-suicide contracts,

their indications, risks, benefits, and contraindications (Miller, Jacobs,& Gutheil, 1998). Thus, most mental health professionals have some ex-

perience with no-suicide contracts, experience that begins early in their

career, and comes in the absence of formal training.

Impact on Behavior

The original research on no-suicide contracts evaluated actual behaviorof patients, who were from diverse settings including hospitals, clinics,

private offices, and community agencies. Clinicians reported that duringthe no-suicide timespan, with clients that they judged to be seriously sui-

cidal, one patient killed herself outside the time period, one died from anoverdose, one died from an ambiguous accident, and one seriously at-

tempted suicide. In contrast, these clinicians reported 20 suicidal deaths

or serious attempts in their practice when they had not used no-suicidecontracts (Drye et al.,1973). This first empirical work on no-suicide con-

tracts contains several methodological flaws: (1) no statistical analyses

were performed on these data; (2) the sizes of the two groups are not

given, so there is no way to compare rates; (3) the time frame was differ-

ent; (4) the authors did not specify the criteria for defining `seriously sui-

cidal; and (5) clinicians memories could have been biased. This first

published empirical investigation of no-suicide contracts was ground-breaking, but the positive effects were obtained in a flawed design.

Another study of actual behaviors reviewed suicide incidence reports

on a child and adolescent inpatient unit. Most of these youth were diag-

nosed with either conduct disorder, major depression, or dysthymia.

Contracts commonly targeted several different kinds of behaviors: (a)

unauthorized running away from the unit or activities; (b) suicide at-

tempts or suicidal talk; (c) physical aggression; and (d) sexual actingout. Among 360 children who were treated at the hospital before con-

tracts were used, 58 children (16.1%) were involved in some sort of inci-

dent. Among 570 children who were treated using contracting for

change, 8 children (1.4%) were involved in some sort of incident (Jones,

OBrien, & McMahon, 1993). This report was also promising and cor-

rected for some of the previous methodological problems, including

reporting rates and correcting for the possibility of retrospective bias.



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However, the data was from charts, the time frames were different, and

staff changes occurred between the no-contracting and contracting per-

iods. Further, there was no random assignment.These factors could have

a profound impact on the data.Research on no-suicide contracts need not be limited to in-person si-

tuations. In a unique approach to studying whether no-suicide contracts

change behavior, researchers listened unobtrusively to 617 callers at two

suicide prevention centers where telephone volunteers had been trained

to contract with the caller. The no-suicide contract involved refraining

from suicide, engaging in a follow-up activity to develop a long-term res-

olution of a suicidal crisis, and making a follow-up contract with thecenter. In the majority of calls (68%), the telephone clinician obtained

a no-suicide contract. Researchers classified those who failed to call back

in a follow-up as non-compliant. Using this conservative definition, the

majority of callers upheld the contracts (54%); some did not make a con-

tract (31%); a minority (14%) failed to keep the contract; and 1% of

callers attempted suicide after calling (Mishara & Daigle, 1997). These

resultsthough limited by the high number lost to follow-up, potentialbiases in retrospective recall, and absence of a control groupsuggestthat no-suicide contracts used on the telephone may change actual

behavior.

Research on the impact of no-suicide contracts on actual behavior has

been promising, though infrequent and flawed, limitations that might be

expected from naturalistic research on low-incidence behavior. How-

ever, the field is now ready for more rigorous research including randomassignment, well-matched control groups, and true experimental ma-

nipulations.

Opinions of Users

An important way to examine whether no-suicide contracts actually

work would be to ask those who use them. Users could include mentalhealth professionals, other professionals who might be called upon to

use no-suicide contracts, or peers of suicidal individuals. Also, users

could include patients who are actually suicidal.

When asked a hypothetical question, practicing clinicians moderately

favor no-suicide contracts. When surveyed, licensed psychologists were

optimistic about no-suicide contracts with moderately suicidal adults

and adolescents but were neutral to slightly pessimistic regarding their



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use with children ages 6711 years and 9712 years, perhaps because chil-

dren of this age are limited in cognitive ability. Further, these clinicians

viewed no-suicide contracts as helpful with moderately suicidal patients,

but only slightly helpful with mildly or severely suicidal patients(Davidson, Wagner, & Range, 1995). Overall, these clinicians viewed

no-suicide contracts as more helpful than harmful, though their positive

feelings about no-suicide contracts were tenuous.

When asked about a specific situation, however, mental health profes-

sionals favor no-suicide contracts. In one survey, 368 clinicians who

worked with children indicated that they were mildly to moderately in

favor of written no-suicide agreements regardless of the reading level ofthe agreement. These practicing professionals saw no-suicide agree-

ments as more appropriate when the child in the vignette had no history

of academic problems, was relatively older (9 to 11 or 12 to 17) rather than

6 years of age, and relatively free of academic problems (Davidson &

Range, 2000).Though clinicians had only moderate faith in the effective-

ness of such agreements, they apparently believed that they would not

hurt child clients. When given a specific situation, experienced profes-sionals saw no-suicide agreements as moderately to strongly appropri-ate, though only mildly to moderately effective.

Are the opinions of mental health professionals the same as the opi-

nions of other professionals, such as educators? It is reasonable to ex-

pect that teachers will face suicidal students at some time during their

careers (Davidson & Range, 1997). Educators need to know the danger

signals of suicide and how to use appropriate intervention techniques(McBrien, 1983), one of which could be a no-suicide contract. In one

study, 63 practice teachers reported that they would take direct action

by calling the parents of a suicidal youth, escorting the youth to the

school counselor, and staying with the youth until another adult ar-

rived. They were neutral about whether they would use a written or

verbal no-suicide agreement. These findings were true regardless of

the age of the student or the level of risk (Davidson & Range, 1997).Thus, although these teachers-in-training expected to act when a stu-

dent was suicidal, they were neutral about whether this action would

be to use a no-suicide contract.

Teachers less-than-positive attitude may be due to an absence of

training in how to deal with suicidal youth during their careers. How-

ever, they are responsive to training in this area. After one in-service

training module about suicide warning signs and no-suicide contracts,



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teachers were more certain that they would actively intervene when con-

fronted with a suicidal student. Interventions that they endorsed in-

cluded physically escorting the suicidal youth to the counselors office

and calling his or her parents. They changed from uncertain=slightlylikely to highly likely to use a written or verbal no-suicide agreement.This shift from neutral to proactive is important because teachers may

be the first or only adults to have an opportunity to interact with a suici-

dal youth (Davidson & Range, 1999). Thus, teachers may be initially

neutral to slightly positive about no-suicide agreements, but after brief

in-service training become strongly positive.

In addition to clinicians and teachers as potential users of no-suicidecontracts, still another potential user is the peer of a suicidal individual.

Peers are often the first person contacted by a suicidal individual. In a

survey of 396 students from 19 health classes at two southwestern high

schools, some had been taught to use no-suicide agreements but few had

ever called a crisis hotline or contacted a counseling service. However,

about 50% said that they would share suicidal thoughts with a friend.

Further, these students were responsive to training in no-suicide con-tracts. At one and seven weeks, those who received training were morelikely than others to say that they would obtain a no-suicide contract

from a suicidal peer (Hennig, Crabtree, & Baum, 1998). Thus, peers

as well as professionals are responsive to training about no-suicide

contracts.

A different approach to assessing users would be to ask suicidal indi-

viduals themselves. One such project accomplished this objective.Among 39 psychiatrically hospitalized children (mean age =13.3 years),

researchers defined suicidal behavior as suicide attempts, suicidal talk,

and self-mutilation including cutting, scratching, tattooing, and writing

on oneself (Jones & OBrien,1990). The treatment involved developing a

written contingency contract in which children received privileges based

on meeting the terms of the behavioral agreement. Children used a vari-

ety of contracts, including but not limited to no-suicide contracts. Then,they completed a 32-item questionnaire assessing the efficacy of various

treatments they received, including contracting. They rated the con-

tracting ``very high in helping them change their behaviors but were

only moderately interested in continuing to contract after discharge

(Jones & OBrien, 1990). A limitation of this study was that no informa-

tion was provided on whether childrens responses to the questionnaire

were confidential or anonymous, so the effects of social desirability on



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their ratings are unknown. In addition, there was no concurrent collec-

tion of data on the incidence of suicidal behavior (Drew,1999). Also, this

naturalistic study failed to include random assignment. Perhaps only the

healthiest children were willing or able to use no-suicide contracts.Furthermore, the hospital staff changed over time. Nevertheless, this re-

search showed that hospitalized inpatient children had a positive atti-

tude toward no-suicide contracts as part of treatment. This study was

unique in that it ascertained the attitudes of potentially suicidal indivi-

duals, rather than those who deal with them.

Research on no-suicide contracts has surveyed frequency, compared

actual behavior with and without no-suicide contracts, and assessed theopinions of users. Each approach has merits as well as limitations. Fre-

quency surveys can reveal the current standard of care. Actual deaths

are a powerful index of whether no-suicide contracts work, but few ac-

tual deaths occur in a low-base-rate phenomenon such as suicide; some

deaths are ambiguous, and researchers are sometimes unable to ascer-

tain cause of death, or even that a person died. Actual attempts are also

a powerful index of whether no-suicide contracts work, but attempts arehard to measure because patients may misreport, be lost to follow-up, orprovide answers biased by social desirability or other distortions. Opi-

nions of users are also a valuable index of effectiveness, but opinions

could be biased by their retrospective nature, potential for self-serving

or other biases, or by the fact that the questions are hypothetical. Most

research on opinions has examined the opinions of professionals, with a

few exceptions (Jones et al.,1993; Mishara & Daigle,1997) very little hasassessed the opinions of potentially suicidal individuals who used no-

suicide contracts.

Recommendations

There is a paucity of literature on no-suicide contracts. More research isnecessary on how no-suicide contracts affect actual rates of attempts and

completions, and opinions of users. Also, mental health training on sui-

cide is sparse. More is needed, particularly on how and when to use no-

suicide contracts. Despite these limitations, clinical recommendations

about the use of no-suicide contracts can be gleaned from the clinical

and research literature.



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Research

Research that examines actual death rates has great value, though the

low base rate of suicidal behavior makes such research difficult.

Further, because no-suicide contracts may be helpful, no one has yetdesigned a research project that involved deliberately withholding

them from suicidal individuals. An alternative paradigm would be to

conduct a prospective study of a large number of suicidal individuals,

assessing attempts as well as completions. For example, one could make

a no-suicide contract part of the check-out procedure of a psychiatric

hospital, comparing the suicide rate among those who had this addi-

tional step with the rate among those who had a routine discharge

procedure.

Assessing callers to a telephone hotline (i.e., Mishara & Daigle,

1997) is a novel approach. We recommend this type of creativity in re-

search design involving no-suicide contracts. For example, one could

deliberately obtain no-suicide contracts with one group of callers but

not another, then query them later about whether the intervention

was helpful.

Research on suicidal people who used no-suicide contracts has great

value. Only one nursing study (Jones & OBrien, 1990) has actually

used this procedure. We recommend more research of this type. Fol-

lowing Jones and OBrien, one could assess opinions about a variety

of aspects of treatment, of which no-suicide contracts are one compo-

nent. Also, one could query suicide attempters, asking them if a no-suicide contract would have deterred the attempt. Alternatively, one

could query clinical inpatients or outpatients about whether or not ano-suicide contract would make a difference to them. Qualitatively,

one could ask those who had been suicidal what aspects of the contracthelped or hurt, or what they would recommend with regard to no-

suicide contracts.

Training

Most (70%) practicing psychologists (Peruzzi & Bongar,1999) and psy-

chology trainees (55%, Kleespies,Penk, & Forsyth,1993) report some for-

mal training in the study of suicide, though it is typically only one or two

lectures (Kleespies et al.,1993) and could be described as cursory (Nei-

meyer, 2000).Training is needed, given that in one survey approximately



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97% of psychology trainees reported working with suicidal individuals,

29% had at least one client who attempted suicide, and 11% of trainees

hada clientcommit suicide (Kleespies et al.,1993).

Training in dealing with suicidal individuals should begin early in thetraining program and continue throughout all aspects of the prepara-

tory experience (Westefeld et al., 2000). One necessary component of this

training should be the use of no-suicide contracts. Training can be pro-

vided formally and informally. At a minimum, training should include

at least one didactic course with content in both suicide and death

(Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). Supplemen-

tary offerings such as workshops, discussion groups, and=or experientialexercises, optimally led by a multidisciplinary team, could be added to

help trainees feel comfortable around suicidal persons, as well as the gen-

eral topic of death (Chemtob et al.,1989).

In addition to knowledge, training should focus on values clarifica-

tion and anxiety reduction (Neimeyer, 2000). Toward this end,

readings on the ethics of suicide prevention could be supplemented

with relevant self-exploration exercises. Reflection on shared andunique concerns in a supportive environment, in combination withclose mentoring and graded exposure to working with highly per-

turbed clients, could support trainees in developing competencies

with suicidal individuals, a very demanding client population

(Neimeyer, 2000). Training in no-suicide contracts should not be left

to happenstance but should be addressed through well-organized, co-

herent training integrated in the core requirements for all mentalhealth professionals.

This training should be evaluated. Questions with regard to training

include whether some groups might be more responsive than others, and

which components of training are most helpful for which people.

Further, evaluating no-suicide contracts should include a follow-up com-

ponent.

Clinical

Good no-suicide contracts are specific. They begin with a clear state-

ment of the purpose of treatment, a purpose to which both parties mu-

tually agree (Miller, 1990). They are specific and detailed in what

qualifies as a violation of contract and what are the exact definitions of

terms in the contract (Murphy, 1988). The wording of a contract should



16/24

ensure that all parties comprehend the contingencies. (See Appendix F

for a detailed example.)

Good no-suicide contracts are individualized.They provide for alter-

native coping mechanisms (Miller, 1990), and a back-up plan that typi-cally consists of phone numbers and names of people to call in case the

person can not keep the commitment (Brent, 1997). The back-up plan

might be a telephone crisis line, a hospital emergency room, the thera-

pists beeper, the individuals family or friends, or some combination.

A standardized form may feel coercive to the client and may create a

power differential between the therapist and the client. Therefore, hav-

ing the client write out his or her own contract is desirable.Some special recommendations are in order for using no-suicide con-

tracts with children. Researchers and practitioners may want to add a

statement about who will be informed (parents or guardians) if the child

reveals suicidal thoughts or inclinations (Davidson & Range, 2000).

Further, beyond understanding specific words, practitioners should be

very careful to insure that the child fully understands what it means to

promise to refrain from self harm. One way to accomplish this goalwould be to ask the child to repeat back, in his or her own words, whathe or she understands the promise to mean (Davidson & Range, 2000).

A no-suicide agreement is no substitute for interacting with the child,

conveying care and concern, and taking concrete action if needed.

Good contracts are collaborative. In addition to the clinician and the

client, a collaborative approach might also include parents, teachers,

peers, and other involved parties. Active client involvement in the con-tracting process is responsive to ethical guidelines requiring fully in-

formed consent regarding treatment procedures and goals (Murphy,

1988). Collaborated contracts are much preferred to dictated ones.

Good contracts are positive in wording and in reinforcement. Positive

wording might include the agreement to keep oneself safe (Sills, 1997).

Many individuals, such as those with borderline personality disorder,

have experienced rejection, punishment, and emotional, sexual, and=orphysical abuse.Therefore, punishment may simply repeat a familiar pat-

tern. The therapist should reinforce the client for meeting short-term

goals, which may reduce feelings of helplessness (McLean & Taylor,

1994). Therefore, omit penalty clauses from no-suicide contracts.

Good contracts are context-sensitive. The no-suicide contract should

occur within the context of a therapeutic relationship. Realistically, no-

suicide contracts are often necessary on the first visit, when the clinician



17/24

has no history with the patient, and little time to forge a relationship.

Nevertheless, some time to hear the patients pain, actively listen to his

or her story, is a solid foundation that will help enable client and clini-

cian to struggle through a suicidal crisis. The no-suicide contract will bemore beneficial after a therapeutic alliance is established than as an in-

itial step. No-suicide contracts are only one step in a therapeutic inter-

vention with a suicidal individual.

One aspect of context that could be overlooked is the suicidal indivi-

duals background. If the suicidal individual is a member of a minority

group and the mental health professional is not, the clinician should as-

certain whether the agreement is meaningful to the person. If religion isan important aspect of the suicidal individuals life, the clinician should

ascertain how the contract fits with his=her religious beliefs. If the suici-dal individual has prior experience with behavioral contracting, the

clinician should ascertain whether or not this experience was helpful.

Another aspect of context that could be overlooked is the therapists

frame of mind. The clinicians reaction (i.e., anger, frustration, etc.) to

suicidal patients is very complex and may result in aversive, thoughtless,irrelevant, cynical, or coercive use of the no-suicide contract (Milleret al., 1998). Alternately, no-suicide contracts may reduce the clinicians

feelings of helplessness, anger, frustration, and confusion to the point

where he or she is able to use more effective and efficient techniques with

current and future patients (Assey, 1985). Professionals should negotiate

no-suicide contracts when they are in a good frame of mind. Because

suicidal individuals are often very difficult and demanding clients, usinga no-suicide contract should be considered as a sign that the therapist

would benefit from supervision or consultation.

Good no-suicide contracts are limited. Rather than being a forever

promise, no-suicide contracts have a limited time frame, such as until

the next appointment. For an educator, it might be until tomorrow, until

our next meeting together, or until Monday morning. Time-limited

promises are easier to keep than forever promises.Even good no-suicide contracts are no substitute for thorough assess-

ment. In addition to the clinical interview, a thorough assessment might

include traditional questionnaires, brief screening measures, or non-

traditional instruments. Traditional suicide questionnaires include the

Scale for Suicide Ideation (Beck, Kovacs, & Weissman, 1979), which can

be completed by a clinician, a paraprofessional, or by the suicidal indivi-

dual; the Suicidal Ideation Scale (Rudd, 1989); the Suicide Probability



18/24

Scale (Cull & Gill, 1982); the Reasons for Living Inventory (Linehan,

Goodstein, Nielsen, & Chiles,1983); and the Suicidal Ideation Question-

naire (Reynolds, 1987), which comes in adult, junior high, and senior

high versions. Brief screening instruments include the Suicide BehaviorsQuestionnaire (Cole,1988), which comes in adult (Cole,1988) and child

(Cotton & Range, 1993) versions; and the Suicide Status Form (Jobes,

Jacoby, Cimbolic, & Hustead, 1997). Non-traditional instruments in-

clude Multi-Attitude Suicide Tendency Scale (Orbach et al., 1991); and,

the Fairy Tales Test (Orbach, Feshbach, Carlson, Glaubman, & Gross,

1983), a projective technique for children. For a review of 20 suicide as-

sessment instruments, see Range and Knott (1997). No-suicide contractsare no substitute for standardized, validated instruments, and cannot re-

place a clinical interview for assessing suicidality.

Though they provide good documentation of therapist efforts to pre-

vent suicide, no-suicide contracts are no guarantee against lawsuits.

Documentation that avoids shorthand (such as ``patient contracted for

safety) is helpful (Miller, 1999), but the therapist should not be fooled

into thinking that using a no-suicide contract will prevent a malpracticesuit. No-suicide contracts are not legal documents. For this reason, clin-icians should avoid the word contract in their clinical interactions with

suicidal individuals, choosing instead `agreement, ` promise, or `com-

mitment.

Good contracts are copied. The final step in treating suicidal indivi-

duals is to elicit and maintain a commitment to stay alive, avoid suici-

dal behavior, and use problem-solving strategies learned in therapy(Linehan, 1999). Whether these commitments should be written or not

is a matter of personal preference (Linehan, 1999). If they are written,

however, copies should go to the patient, the therapist, and at times the

family and=or staff (Miller, 1990). Written materials that outline thenature of treatment, its goals, and the expectation of the patient could

have a beneficial educational effect and may reduce strain (Miller,

1999).No-suicide contracts that are specific, individualized, collaborative,

positive, context-sensitive, and copied as needed are part of the arma-

mentarium with which a clinician deals with a suicidal individual.They

are not a thorough assessment, they are not a guarantee against legal

liability, and they are not a substitute for a caring, sensitive therapeutic

interaction. Nevertheless, used respectfully and empathically, they can

be a useful adjunct to treatment for a suicidal individual.



19/24

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Appendix A: Actual No-Suicide Contract

I, _______________________________________ _____ agree that I will not do anything that would cause

harm to myself or anyone else, for the following length of time:

____________________________________ ________.

I realize that I am responsible for my own actions, and that if I feel mylife is becoming too difficult, I agree to do one or more of the following

actions so that there is no harm to myself or others. Call

1. ___________________________________ ________ _ at ____________________________________ ________,

or

2. ___________________________________ ________ _ at ____________________________________ ________,

or

3. ___________________________________ ________ _ at ____________________________________ ________,

or I will go to the emergency room.___________________________________ ________ _ _____________________________________ _______Client Signature Date___________________________________ ________ _ _____________________________________ _______

Witness=Counselor Signature Date



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Appendix B: No-Suicide Agreement

for 6- to 8-Year-Old Child

I, _____________________________________ _______, will do these things.1. I want to live a long life and be happy.

2. I will come to counseling to learn how to be happy.

3. While I learn how to be happy, I will not hurt or kill myself. I

know it will take time to learn how to be happy.

4. If I ever want to hurt or kill myself I will tell _____________________________________ _______ or I

will tell _____________________________________ _______.

5. My counselor, __________________________________ __________ , will help me learn how to be happy.

6. I will do all of these things until ____________________________________________ , when I see my

counselor, ___________________________________ _________, again.

____________________________________ _______ _ _____________________________________ ______ _

Name Date____________________________________ _______ _ _____________________________________ ______ _

Witness: Name Date

Appendix C: No-Suicide Agreement for 9711-Year-Old Child

While I am in counseling, I, ___________________________________ _________ , will do these things.

1. I want to live a long life and be happy.

2. When I feel bad and I want to hurt myself or kill myself I can notbe happy. I will come to counseling to learn how to be happy.

3. While I learn how to be happy I will not hurt or kill myself. I

know it will take time to learn how to be happy.

4. If at any time I want to hurt or kill myself, I will tell __________________________________ _________ _

or I will tell ____________________________________________ . If I cannot find ___________________________________________ _ or

____________________________________ _______ _ I will call ____________________________________ _______ _ or __________________________________ __________.

5. My counselor, ___________________________________ _________ , agrees to work with me to help melearn how to be happy.

6. I agree to keep this agreement until __________________________________ __________ , when I see my

counselor again.

____________________________________ _______ _ _____________________________________ ______ _

Name Date

____________________________________ _______ _ _____________________________________ ______ _

Witness: Name Date



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Appendix D: No-Suicide Contract for 12717-Year-Old

Child=Adolescent

As part of my counseling, I, ____________________________________ ________, will dothefollowing things.1. I agree that one of my major goals is to live a long life with more

happiness than I now have.

2. I understand that wanting to hurt myself or kill myself gets in the

way of this goal. I want to learn better things I can do when I feel

bad. I want to find answers to my problems.

3. I understand that feeling better will take time so I will not hurt or

kill myself between now and ___________________________________ _________, when I see my coun-

selor again.

4. If at any time I want to hurt or kill myself I will tell ____________________________________ ________

or _____________________________________ _______. If I cannot find __________________________________ _________ _ or ____________________________________ _______ _

I will call ___________________________________________ _ at ___________________________________________ _ or ___________________________________________ _ at

__________________________________ __________ .

5. My counselor, __________________________________ __________ , will work with me to help me learn

better ways to take care of my problems. My counselor,

__________________________________ __________, will be available as much as possible if I feel very

upset.

6. I will keep this agreement until it expires or until ___________________________________ _________ ,

when I see my counselor again. My counselor and I can then

make another agreement if we need to.

__________________________________ _________ _ ___________________________________ ________ _Name Date

__________________________________ _________ _ ___________________________________ ________ _

Witness: Name Date

Appendix E: School-Based No-Suicide Contract

I, ___________________________________________ _ (name) ____________________________________________ , a student at ___________________________________________ _

(school) ______________________ _____________________ _, take the responsibility for my welfare, and

I agree not to harm myself in any way. I understand that if I am having

suicidal thoughts, I agree to call my counselor, ____________________________________ _______ _ (name), at

___________________________________________ _ (phone number). If I cannot reach my counselor, I will

call the crisis hotline at ___________________________________ ________ _ (phone number) or I will tell the

nearest adult and get help for myself.



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Appendix F: Detailed No-Suicide Contract

As a part of my therapy program, I, _____________________________________ _______, agree to the fol-

lowing terms.

1. I agree that one of my major therapy goals is to live a long life with

more pleasure and less unhappiness than I have now.

2. I understand that becoming suicidal when depressed or upset stands

in the way of achieving this goal, and I therefore would like to over-

come this tendency. I agree to use my therapy to learn better ways to

reduce my emotional distress.3. Since I understand that this will take time, I agree in the meantime to

refuse to act on urges to injure or kill myself between this day and

_____________________________________ _______.

4. If at any time I should feel unable to resist suicidal impulses, I agree to

call __ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (name) at ___ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ (number) or

_____________________________________ _______ (number). If this person is unavailable, I agree to call

___________________________________________ _ (name) at ___________________________________________ _ (number) or ___________________________________________ _(number) or go directly to ___________________________________ _________ (hospital or agency) at_____________________________________ _______ (address).

5. My therapist, ___________________________________ _________, agrees to work with me in scheduled ses-

sions to help me learn constructive alternatives to self-harm and to be

available as much as is reasonable during times of crisis.

6. I agree to abide by this agreement either until it expires or until it is

openly renegotiated with my therapist. I understand that it is renew-able at or near the expiration date of ___________________________________ ________ _ (date).

____________________________________ _______ _ __________________________________ _________ _ ____________________________________ ________ _____________________________________ _______

Signature Date Therapists Signature Date

Note. Adapted from Bongar,1991, and Fremouw, de Perczel, and Ellis,

1990.


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