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Maureen Werrbach Apr 5, 2011

Reliability of No-Harm Contracts

Before I started working at the hospital, I had no experience with using no-harm safety contracts, nor did I have much of an opinion on their usefulness. I remember vaguely learning in grad school about them, something about using them to cover ourselves if things go bad. Not much was mentioned about their reliability, when and how to use them and the different types of safety contracts, i.e. for non-suicidal self injurers and well as those with passive suicidal thoughts. I learned early on that it is standard at most hospitals to use safety contracts with patients who report passive suicidal ideation, or who do not meet criteria for inpatient treatment, or are non-suicidal self injurers. So, without much thought about it, I have been using them for patients that are not clinically appropriate for inpatient treatment but may have had passive thoughts of self harm without suicidal intent, just as I had been requested to do per hospital policy. Now, I have to admit there have been times after having a patient sign the safety contract that I thought to myself, ‘Would signing this piece of paper actually stop this person from harming themselves if suddenly they were to become overwhelmed with active thoughts of self harming in the near future?’ Sometimes I felt like it did not make sense to use them, especially in the setting that I work in. Let me explain. I meet with patients for no longer than one hour, and I usually never see them again (unless they present in the ER again). What obligation to they have to me to keep that promise of not harming themselves once they return home? It seems appropriate, let’s say, for a counselor who has been treating someone for a reasonable period of time and has established a good relationship to feel safe using a safety contract with that person. But how well can we know a person within one hour to know that they are signing a safety contract with the intent on following through with the agreement? Can we see if a person is only agreeing to a safety contract and not admitting to more severe suicidal thoughts with intent in order to not be admitted inpatient? I read an article in the last Journal of Counseling and Development about safety contracts that brought to light so many good concerns as well as justifications to using them. So I’ve decided to see what you all think about them. Do you use them? What are your thoughts about using them? Are there specific situations in which their use seems more appropriate than others?

Maureen Werrbach is a counselor who works at a hospital and provides clinical assessments in the areas of mental health and substance abuse.

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