It seemed like the simplest thing. A few years ago, a client of mine had been thinking a bit about suicide, but without a specific plan or intent. They would be considered far too low-risk for hospitalization or other crisis services. But I was worried enough that I didn’t want to just send them on their way without doing something. So we wrote out a no-harm contract.
No-harm contracts involve a commitment from the client, often signed, that they will not do anything to harm themselves or anyone else before a specific date. Often that date is the next time the client and therapist will meet, so that the client can be reassessed and the contract revised and re-signed as needed. Some no-harm contracts include specific steps the client would be expected to take before engaging in any harmful behavior.
I gave my client a copy of the contract, and kept the original in the client’s file. I thought I had done the right thing.
When I told my supervisor, I expected a pat on the back.
Instead, I almost lost my job.
The problem with contracting
A no-harm contract isn’t a contract in any legally enforceable sense. If that client actually had hurt themselves, it’s not as though my agency was going to sue the client for breach of contract. There’s no way to meaningfully hold someone to it.
What a no-harm contract does, though, is establish in writing that I believed the client posed some level of risk to themselves. And that, after I recognized that risk and saw a need to intervene, I simply took the client at their word that they would be fine.
This is why no-harm contracts have fallen out of favor over time. There’s no evidence that they work. They may even provide you a false sense of security. They show that you saw a need to intervene to reduce suicide risk, and then that you didn’t actually do much to intervene. Legal scholars have expressed concern that this could open therapists up to legal liability if a client dies by suicide* and the family files a complaint or lawsuit.
What to do instead
If you have a client who you believe poses a risk to themselves or to others, but that risk is not significant enough to warrant more intrusive forms of intervention, then it is generally considered best to develop a specific safety plan. That plan involves a sequence of specific actions the client can take, ranging from minimal tasks like journaling or calling a particular friend to crisis options like going to an emergency room or calling the National Suicide Prevention Lifeline (800-273-8255). It ensures that the client knows exactly what to do if they feel their mental state deteriorating, even if you aren’t immediately available.
A safety plan may be one component of a more comprehensive safety strategy. That strategy may also include steps like increasing the frequency of contact, involving other health care professionals, increasing social support, and removing access to lethal means.
That’s not the only change
Suicide prevention, assessment, and intervention has actually changed in a number of meaningful ways in the past few years. For example, new research is telling us that screening instruments aren’t all that useful, and that many clients will not talk about their suicidal thoughts even when asked directly. These findings shape how we work with clients who may be contemplating suicide.
In response to rising suicide rates, a number of states implemented additional suicide training requirements for therapists.
To learn more about safety planning, current research, and much more, you can take our 6-hour continuing education course on Suicide Prevention, Assessment, and Intervention at SimplePractice Learning.
And for what it’s worth: The next time my client came in, we created a more thorough safety plan. I kept my job, and, more importantly, the client stayed safe.
* One important recent change is that we now try to avoid the term “committed suicide.” Language continues to evolve. There are good guidelines for media reporting on suicide to avoid sensationalizing the topic or casting judgment on those who attempt or die by suicide.
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