‘No suicide contracts’ in community crisis situations: a conceptual analysis

Abstract

'No suicide contracts' are commonly used in community crisis situations with suicidal people in New Zealand. These take the form of a 'guarantee of safety', along with a 'promise' to call specified persons if the suicidal ideation becomes unmanageable. This article describes the use of 'no suicide contracts' in community crisis situations, analyses the use of the tool within this context, and, in particular, argues that the theoretical base (transactional analysis) of the 'no suicide contract' is likely to be deleterious in the community crisis situation.

Do ‘no‐suicide’ contracts work?

“…Transactional analysis is based on the theory that there are three ego states: child, adult and parent. Farrow (2003) highlights the argument proposed by Lester (1994) that, as suicidal feelings belong to the child ego state, the role of the therapist is to help the service user move from this state to the mature adult state and that, rather than facilitating this process, asking a service user to ‘promise’ not to kill themselves merely reinforces ‘the executive role of the child's ego state’ (p. 369), hence being at odds with TA principles. Similarly, Farrow (2003) alludes to the power imbalance in the transaction, suggesting that the request to enter into an NSC reinforces the ‘child’ role of the service user, who is forced to agree to an action by the ‘parent’ (clinician), for fear of retribution.…”

“…NSCs are usually used with the intention of preventing all forms of self‐harm, not just suicide. They have been used in various contexts, including emergency helplines and inpatient units (Farrow 2003) and they commonly comprise a statement of assent, details of the duration of the agreement and a contingency plan in the event that the service user feels unable to uphold the agreement (Range et al. 2002).…”

Suicidal Clients in the Home

“…Because of this lack of evidence to support their outcomes, NSCs are seen by some as being somewhat controversial, unpredictable, and even unreliable (McMyler & Pryjmachuk, 2008). Nonetheless, NSCs continue to be used in many psychiatric inpatient units in the United States for treating acutely suicidal clients (Farrow, 2003;Potter et al, 2005;Varcarolis & Halter, 2010, p. 558).…”

Pragmatism rules: the intervention and prevention strategies used by psychiatric nurses working with non‐suicidal self‐harming individuals

“…The terms no‐harm contracts and no‐suicide contracts, used interchangeably in the literature, have been described as verbal or written agreements between a service user and a health professional, intended to prevent self‐harm or suicide (Farrow 2003). Drew (2001), in a retrospective study of 650 medical records in two psychiatric inpatient units, found that no‐harm contracts, used with 33% of patients, did not prevent self‐harm.…”

“…(2002) reported benefits in using ‘no‐harm contracts’. On balance, no‐harm contracts are considered not to be effective in preventing self‐harm (Potter & Dawson 2001, Range et al . 2002, Farrow 2003, Farrow & O’Brien 2003).…”