No-Suicide Agreements: Current Practices and Opinions in a Canadian Urban Health Region

Abstract

Objective: To determine the extent to which no-suicide agreements (NSAs)-one method of intervening with people at risk of suicide-are used by a population of outpatient mental health therapists in a Canadian urban health region, and to describe therapists' perceptions and practices surrounding their use. Method: The survey was mailed to 516 therapists, including psychiatrists, psychologists, nurses, social workers, and occupational therapists. Results: Completed surveys were returned by 312 therapists (response rate = 60.5%). NSAs were used by 83%, although 43% had no formal training in their use. Among those who had used NSAs, 31% reported having had at least one patient attempt or complete suicide while an agreement was in place. Therapists from nonmedical disciplines were most likely to have used these agreements. Most therapists believed NSAs communicated care and concern to patients. Respondents were divided in their perceptions of whether NSAs afforded liability protection in the event of a patient suicide. Contextual factors associated with the perceived degree of suicide risk, the patient-therapeutic relationship influenced a therapist's use of NSAs. Most therapists attempted to have patients admitted to hospital if the patient refused to enter into an NSA. Conclusions: Use of NSAs is prevalent in this population of outpatient psychotherapists, suggesting that these therapists believe they are a useful intervention in the management of suicidal patients. Practitioners might benefit from increased formal training opportunities in the use and legal implications of NSAs.

No-Suicide Contracts, No-Suicide Agreements, and No-Suicide Assurances

“…In the present study, practitioners were using SPC procedures on average 50% of the time as a preemptive defensive (medico-legal) intervention. The use of SPC for self-protection has also been reported by practitioners in Canada, North America, and New Zealand (Davidson et al, 1995;Farrow, 2002;Mahrer, 1993;Page & King, 2008;Sanders et al, 2006).…”

How the psychiatrists of a mental health department managed their patients before an attempted suicide

“…Nonetheless, adoption of this technique should be viewed as only one part of a comprehensive suicide‐risk‐management strategy 30 . In this respect, a minority of the psychiatrists in our survey provided general advice on improving preventability.…”

“…Nonetheless, adoption of this technique should be viewed as only one part of a comprehensive suiciderisk-management strategy. 30 In this respect, a minority of the psychiatrists in our survey provided general advice on improving preventability. None of them suggested using other simple suicide prevention strategies that are widely documented in the literature (although their efficacy remains controversial), as the 'green card' or 'crises lines' between one clinical assessment and the next.…”

Strategies for Managing Difficult Clinical Situations in Between Sessions

“…The no-harm agreement may be oral or written between the client and therapist. It is an agreement stating that the client will not harm or kill themselves and call someone in their support system or emergency personnel before taking their life (Page and King, 2008). There is evidence that the no-harm agreements benefit the client and the clinician by facilitating increased commitment to positive action by the client, strengthening the therapeutic alliance, lessening anxiety, aiding in the assessment of suicide risk, and providing a means of documenting what was done to care for the client’s safety (Page and King, 2008).…”

“…It is an agreement stating that the client will not harm or kill themselves and call someone in their support system or emergency personnel before taking their life (Page and King, 2008). There is evidence that the no-harm agreements benefit the client and the clinician by facilitating increased commitment to positive action by the client, strengthening the therapeutic alliance, lessening anxiety, aiding in the assessment of suicide risk, and providing a means of documenting what was done to care for the client’s safety (Page and King, 2008). The clinician must also be careful to consider that a no-harm agreement may provide the client with possible means of support, but be aware that a no-harm agreement does not completely reduce the risk of a suicide attempt (Page and King, 2008).…”