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The No Harm Contract in the emergency assessment of suicidal risk
E J Stanford1, R R Goetz, J D Bloom
1Department of Psychiatry, Oregon Health Sciences University, Portland 97201.
Background:
The No Harm Contract has been widely accepted in clinical practice, yet there is no broad consensus as to its value. This paper examines the contract and offers recommendations for its use as well as cautions about its misuse.
Method:
After a literature review, the No Harm Contract is examined from diagnostic, therapeutic, and medicolegal perspectives.
Results:
Diagnostically, the No Harm Contract can be used to assess the nature and severity of a patient's suicidality, uncover specific troubling issues precipitating suicidal thoughts, and evaluate the patient's competency to contract. Therapeutically, the contract affords an opportunity to initiate a therapeutic alliance, establish the limits of the psychotherapeutic framework, and reduce both patient and clinician anxiety. Medicolegally, the contract is not legally binding and grants no suicide malpractice suit protection.
Conclusion:
Although the No Harm Contract is a frequently used clinical tool that can provide diagnostic information and therapeutic advantage, it can also short-circuit comprehensive suicidal assessment and disposition decisions.