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Journal Critique
Introduction
The following paper will summarize and critique three journal articles related to no-
suicide contracts, or similarly named agreements.
Journal 1
In their 2008 article from the Journal of Psychiatric and Mental Health Nursing, Do no-
suicide contacts work?, Mcmyler and Pryjmachuk argue that the use of contracts as an
effective clinical tool lacks evidence and quantitative support. The authors contend that not only
do contracts fail to substantiate use through data, but that contracts present ethical and
conceptual concerns as they can limited the choices of the patient at a time when they might
already be struggling for control.
The authors discuss weaknesses in a founding study on No Suicide Contracts (NSCs) by
Drye (1973) in which the study showed that 32 therapists had used NSCs for 5 years with 100%
success among 1209 cases. However, success was only determined as cases which did not result
in a completed suicide. No data was collected on clients who attempted suicide after
participating in a NSC. A follow-up study found that in 43% of 617 cases where NSCs were
used, self-harm did occur after the NSC had been established.
Additionally, the authors note a 2001 retrospective study where medical records were
reviewed from one hospital using NSCs and another not using them, and found that in the
hospital where NSCs were used, self-harm was five times higher among patients. Such
occurrences are believed to be attributed to the binding and restrictive nature of NSCs.
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In conclusion, the authors were unable to find what they consider adequate quantitative
evidence to support the NSC as a clinically effective tool. From a qualitative standpoint, the
authors found reviews showing strong opposition to the tool from both clients and clinicians.
Journal 2
In their 2006 article, The Case Against No-Suicide Contracts: The Commitment to
Treatment Statement as a Practice Alternative, authors Rudd, Mandrusiak, and Joiner review
literature on the use and effectiveness of No Suicide Contracts (NSCs) and ultimately offer an
alternative practice to NSCs in Commitment to Treatment Statements (CTS).
The authors identify that common elements among NSCs are: an explicit statement
agreeing to not harm or kill oneself, specifics about the duration of the agreement, a contingency
plan if a crisis arises that would jeopardize the patients ability to honor the contract, and specific
responsibilities. The authors feel that such a contract may limit open and honest communication
because patients may have nothing additional to gain by signing a contract. They also feel that
the lack of clear definitions common to NSCs terminology and failure to provide a clear
theoretical model add to the unsettling aspects of NSCs.
In place of a NSC, the authors have proposed the use and study of a Commitment to
Treatment Statement (CTS). A CTS is described as a handwritten and individualized agreement
between the patient and clinician in which the patient agrees to make a commitment to the
treatment process and living by (1) identifying the roles, obligations, and expectation of both the
clinician and the patient in treatment; (2) communicating openly and honestly about all aspects
of treatment including suicide; and (3) accessing identified emergency services during period of
crisis that might threaten the patients ability to honor the agreement.
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The authors feeling that CTSs target patient motivation and commitment to the treatment
process, outlining core elements and expectations. They also add that it is important that CTSs
have a witness, who should be a significant other or family member who will be involved in the
treatment process, and a crisis response plan to provide direction should the patient encounter a
crisis.
Journal 3
In their 2010 study, Edwards and Sachmann sought to develop a contemporary profile of
Suicide Prevention Contracting (SPC), identifying factors associated with utilization, perceived
effectiveness, and to describe potentially detrimental factors of using SPC.
Using a 61 item, self-reporting questionnaire, 420 mental health practitioners participated
in the study sharing their experiences with three SPC procedures and results. The three
procedures were; (1) no-suicide assurances (NSAs) a brief verbal exchange where the patient is
asked to assure the clinician that they will refrain from suicidal behavior; (2) no-suicide
agreements (NSAg) a verbal agreement characterized by an extended process of negotiation
where a patient agrees to refrain from suicidal behavior for a specified period of time, and safety
plan for crises is developed; (3) no-suicide contracts (NSC) a written document usually co-
signed with similar expectations as an NSAg. The questionnaire profiled the perceived
differences in the diagnostic, therapeutic, and medico-legal utility of the procedures.
The authors concluded that SPCs are a poorly understood and questionable clinical
practice intervention. They advocate for more training and research on the subject of alternative
interventions containing less risk.
References
Edwards, S. J., & Sachmann, M. D. (2010). No-Suicide Contracts, No-Suicide Agreements, and
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No-Suicide Assurances. Crisis: The Journal of Crisis Intervention and Suicide
Prevention, 31(6), 290-302.
Mcmyler, C., & Pryjmachuk, S. (2008). Do no-suicide contracts work?. Journal of Psychiatric
and Mental Health Nursing, 15(6), 512-522.
Rudd, M. D., Mandrusiak, M., & Jr., T. E. (2006). The case against no-suicide contracts: The
commitment to treatment statement as a practice alternative. Journal of Clinical
Psychology, 62(2), 243-251.