Ask an Expert: Do Safety Contracts With Suicidal Patients Work?

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Ask an Expert: Do Safety Contracts With Suicidal Patients Work?

By Douglas Jacobs MD 09/27/16

Safety contracts may be helpful but should never take the place of ongoing assessment.

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Does the contract help?

I'm a clinician in an outpatient treatment program. When confronted by client suicidality, our policy is to get the client to sign a safety contract- or call the police if the client refuses. I've had to do that a couple of times and feel that it doesn't accomplish anything except drive a wedge between me and my client. What would you recommend?

Douglas Jacobs, MD: While safety contracts are commonly used and within the standard of care in both inpatient and outpatient settings, they remain controversial. To date, the literature on safety contracts does not show that they prevent suicide. However, they can be used in the management of a suicidal patient in addition to ongoing assessment and treatment. 

A safety contract can be helpful in educating the patient on their treatment plan. Sometimes patients have difficulty understanding clinical explanations. The contract offers the opportunity to provide a clear explanation of treatment in an effort to reduce stress and anxiety for the patient. Safety contracts are most useful in outpatient settings where there is a positive therapeutic relationship. The contract reinforces the common goal the patient and therapist are working toward and enhances the connection between the patient and the therapist.

If you are concerned that the use of the safety contract would drive a wedge between you and your client, you should talk to your client about why they feel this way. It is important to explain to the patient your concern for his/her safety. If the patient refuses to sign a safety contract that should be taken as a warning sign and a clinical decision should be made regarding patient safety and willingness to comply with treatment. 

It is also important to note that patients have different motivations for signing the contract and their acceptance to sign the contract may not be dependable. It is for this reason that a safety contract should never take the place of an ongoing assessment. Managing a suicidal patient requires frequent visits, monitoring and consideration of medication change, and is dependent upon the clinical judgement of the therapist. Ultimately, it is the relationship between the patient and the therapist that is the most crucial factor in caring for a suicidal patient. 

For more information regarding suicide assessment, see the healthcare providers section of stopasuicide.org.

Douglas Jacobs, M.D., associate clinical professor of psychiatry at Harvard Medical School, is a nationally recognized expert on suicide and depression and a leader in the field of Mental Health. Full bio.

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