A Safety Plan differs from a Contract for Safety in several important ways. Be sure to assess the client for delusions, hallucinations, a thought disorder or a decrease in capacity for reality testing.ĭevelop a Safety Plan with your client. Periodically utilize a tool like the Beck Depression Scale to check for progress with depressed clients. Take time to review risk whenever there is a change in presentation, if symptoms persist or get worse, if medications are changed or if the client talks about terminating.
Use the contract only as a part of a full risk assessment: A comprehensive risk assessment includes an evaluation of risk factors, an understanding of what has precipitated suicidal thinking, assessment of the individuals plan and access to means, investigation of any history of past attempts and identification of resiliency factors and potential supports.Īssess regularly: Risk assessment is a dynamic process and should be done regularly with clients who present with or have a history of suicidality or self-harm. When the client is in crisis, consider increasing the frequency of sessions or other types of contact. It can be a relief to a long term client that you are taking her despair seriously and that you care enough to explore whether such an agreement would be helpful.
Secondly, some clinicians seem to think that the use and documentation of a CFS protects them from legal liability if the client does commit suicideĭevelop the therapeutic relationship: Limit use of a Contract for Safety to clients with whom you have a long-term solid relationship: In such cases, the contract can be a useful way to open a conversation about their intentions and feelings. Doing something, even something that may be ineffective, feels better than doing nothing. Confronted with a suicidal client, the clinician may have heard that such a contract is helpful.
The use of the Contract for Safety has become almost folkloric. There are a number of reasons why clinicians continue to use Contracts for Safety, despite the evidence that when used alone, they may not be helpful and, in some cases, may even be harmful.įirst, most clinicians receive limited training in suicidality. In fact, there is even some evidence that for people diagnosed with Borderline Personality Disorder, a CFS may make things worse. But are they effective?Ĭontracts for Safety have not been found to be useful with suicidal patients who are psychotic, impulsive, depressed or agitated, who have a personality disorder or who are under the influence of alcohol or street drugs the very patients who are the most likely to show up in emergency rooms. Although these original authors only investigated its effectiveness with patients in a long term relationship with their therapist, the use of the tool has since become standard practice for many crisis teams and clinicians, even during an initial interview. Results of Contracts for Safety (CFS), where a client is asked to agree either verbally or in writing that she will not engage in self harm, were first published by Drye, et.al. But the story is a good illustration of the limitations of the often used Contract for Safety. The therapist was experienced and kind and, possibly because he was about the same age, able to connect with a 70-year-old depressed man who was grieving. The daughter was able to persuade her father to go to a therapist.
So what was I supposed to do?įortunately, this story has a positive ending. He knew if he refused hed be admitted and he didnt want to give up the option. His daughter was beside herself: Of course he signed the thing, she told my colleague.