Psychiatric Inpatients' Perceptions of Written No‐Suicide Agreements: An Exploratory Study

Abstract

One hundred thirty-five psychiatric inpatients admitted for suicidal danger were surveyed regarding their views on the benefits/limitations of written no-suicide agreements. A survey instrument developed for this study revealed that these inpatients, for the most part, rated written no-suicide agreements in a positive manner and in ways consistent with clinical opinion expressed in a number of qualitative/expert-opinion articles. Positive views of no-suicide agreements were not materially influenced by social desirability or age, nor were they moderated by gender, presence/absence of Axis II disorders, or admission suicidal danger. However, patient suicide attempt history (no attempts, one attempt, or more than one attempt) exerted a moderating effect on patients' ratings of the helpfulness of these contracts. Multiple attempters viewed written no-suicide agreements as less helpful than those patients with a single or no prior attempts. The methodological problems and generalizability concerns associated with these results are discussed and future research needs are suggested.

No‐Harm Contracts: A Review of What We Know

“…Many clients expressed fear of unwanted interventions if they did not sign (Farrow, 2002). Davis et al (2002) found clients with previous suicide attempts less positive about contract efficacy. It is assumed that previous suicide attempts imply more serious mental illness.…”

“…NHCs are referred to in the literature using a variety of terms: no‐suicide contract (Buelow & Range, 2000; Davidson & Range, 2000; Farrow, 2002; Farrow & O'Brien, 2003; Kelly & Knudson, 2000), no‐suicide agreement (Davidson & Range, 1997, 2000; Davis et al, 2002; Farrow & O'Brien, 2003; Myers & Range, 2002), contracting for safety (American Psychiatric Association, 2003; Farrow & O'Brien, 2003), a no‐kill contract (Popenhagen & Qualley, 1998), suicide prevention contracts (Assey, 1985; Miller et al, 1998), safety contracts, and no‐suicide decisions (Centre for Suicide Prevention, 2002). These terms are used interchangeably throughout this paper.…”

“…As stated previously, the use of NHCs (written and verbal) is standard procedure in mental health although there is little empirical evidence supporting their effectiveness (Davis et al, 2002; Drew, 2001; Miller et al, 1998). Kelly and Knudson (2000) go so far as to say that no empirical evidence exists, while Chiles and Strosahl (1995) observe that there has been little effort to evaluate the efficacy of contracts or even examine theoretical underpinnings.…”

“…Although suicide is a rare occurrence, clinicians face assessment of clients' risk for suicide on a regular basis. One well‐accepted and widely practiced intervention for suicidal ideation is the use of noharm contracts (NHC) (American Psychiatric Association, 2003; Buelow & Range, 2000; Davis, Williams, & Hays, 2002; Drew, 2001; Farrow, 2002; Farrow & O'Brien, 2003; Miller, Jacobs, & Gutheil, 1998). Opinions about NHCs range from enthusiasm to apathy; however, the literature suggests they are standard practice in the treatment of suicidal ideation.…”

The Suicidal Adolescent

“…Follow-up studies of repeat attempters indicate that as many as a third had previously signed such a contract (10). While this approach might convey to the patient that he or she is being taken seriously, the clinician should not be overconfident about its value.…”