M. David Rudd
Thomas E. Joiner Jr.
Florida State University
This article reviews the literature on the use of “no-suicide contracts” in
clinical practice, including conceptual discussions, patient and clinician
surveys, and a few empirical studies on clinical utility. Our primary con-
clusion is that no-suicide contracts suffer from a broad range of concep-
tual, practical, and empirical problems. Most significantly, they have no
empirical support for their effectiveness in the clinical environment. The
authors provide and illustrate the commitment to treatment statement as
a practice alternative to the no-suicide contract. © 2005 Wiley Periodi-
cals, Inc. J Clin Psychol: In Session 62: 243–251, 2006.
Keywords: suicide; no-suicide contracts; crisis response plan; crisis
The first discussion of no-suicide contracts in clinical practice was in an article by Drye,
Goulding, and Goulding (1973), but Ewalt (1967) most likely provided the earliest ref-
erence to the general idea. Ewalt (1967) provided a wonderfully specific set of recom-
mendations about the process and content of the clinical exchange with suicidal patients,
although it was not identified as a no-suicide contract. A number of other clinicians,
Correspondence concerning this article should be addressed to: M. David Rudd, Ph.D., ABPP, Baylor Univer-
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 62(2), 243–251 (2006)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20227
© 2006 Wiley Periodicals, Inc.
including Shneidman and Farberow (1957), have offered similar discussions about the
process of negotiating with at-risk suicidal patients, although they also did not formally
refer to establishing a no-suicide contract. Similarly, others have provided discussions of
the more broadly defined “therapeutic contract” (e.g., Etchegoyen, 1991), articulating
roles and obligations in the treatment exchange without specific reference to the no-suicide
Drye and colleagues (1973) provided a simple and straightforward method allowing
patients and clinicians to reach an agreement or a “decision” about their suicide risk, with
clear implications for management and treatment. What is perhaps most striking about
their article is the lack of a clear theoretical or empirical foundation to the recommenda-
tions. They provide ample anecdotal support in the form of a statement that in “over 600
cases” they never experienced a suicide, but the lack of theoretical rigor and scientific
precision makes definitive statements about the utility of the instrument problematic.
From a theoretical perspective, this early work does not make it clear whether no-suicide
contracts are an administrative procedure or a clinical intervention driven by an identified
conceptual model.Without question, though, their work was groundbreaking and founded
on clinical wisdom and common sense.
What is troubling is that over the past three decades the state of the art in this area has
not moved much beyond this original work. Despite the methodological and legal chal-
lenges, practitioners seek an empirically supported and clinically useful method to doc-
ument agreements with suicidal patients, with respect to both treatment goals and practical
steps to be taken during periods of acute crisis. In this article, we review the literature on
no-suicide contracts and present a practice alternative to it in the form of the commitment
to treatment statement.
What Is a No-Suicide Contract?
No-suicide contracts are discussed in the literature in a number of ways, including as
no-harm contracts, suicide prevention contracts, no-suicide decisions, or safety agree-
ments or contracts. This list is not exhaustive, but these are the most common terms
discovered. Surprisingly, there does not appear to be any uniform definition of a no-suicide
contract, although there clearly are common elements across all references. Nor does
there appear to be any consensus as to whether such agreements must be written and/or
verbal. More often than not, no-suicide contracts are used specifically with patients who
report suicidal thoughts or behaviors, but in some instances they have been used with all
patients in the form of a broader agreement about the general nature of treatment or care.
Simply stated, a no-suicide contract is an agreement between the patient and clini-
cian in which patients agree not to harm themselves and/or to seek help when in a sui-
cidal state and they believe they are unable to honor the commitment. Common elements
in no-suicide contracts include the following:
• An explicit statement agreeing not to harm or kill oneself
• Specific details about the duration of the agreement
• A contingency plan if a crisis that would jeopardize the patient’s ability to honor
the agreement emerges
• The specific responsibilities of both patient and clinician (Drew, 2001; Rudd, Joiner,
& Rajab, 2004)
A number of problems warrant further discussion. Miller (1999) discussed the prob-
lem with the term contract, aptly identifying the hidden messages embedded in the word,
Journal of Clinical Psychology: In Session, February 2006
Journal of Clinical Psychology: In SessionDOI 10.1002/jclp
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Journal of Clinical Psychology: In Session DOI 10.1002/jclp