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S. J. Edwards & M. D. Sachmann: Suicide Crisis©2010; Prevention 2010 Vol. Hogrefe 31(6):290–302 CoPublishing ntracting

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No-Suicide Contracts, No-Suicide Agreements, and No-Suicide Assurances A Study of Their Nature, Utilization, Perceived Effectiveness, and Potential to Cause Harm Stephen J. Edwards1,2 and Mark D. Sachmann1 1

Discipline of Social Work and Social Policy, University of Western Australia, Australia 2 North Metropolitan Area Health Services, Mental Health, Perth, Australia

Abstract. Background: Suicide prevention contracting (SPC) procedures are often afforded clinical practice validity in the absence of evidence attesting to their efficacy and validity. Aims: This study sought to develop a contemporary profile of SPC, identifying factors associated with utilization, perceived effectiveness, and to describe potentially detrimental factors when activating SPC. Methods: A questionnaire was mailed to a sample of mental health practitioners comprising physicians, mental health nurse practitioners, and allied health practitioners to inquire about their practices and experiences with SPC. Results: There were 420 valid responses, a response rate of 31%. Participants confirmed three types of SPC procedures in operation: (1) 355 (85%) having used verbal no-suicide assurances (NSAs); (2) 317 (76%) using verbal no-suicide agreements (NSAg); and, (3) 154 (37%) using written no-suicide contracts (NSC). The profiled procedures and their clinical application indicate that participants perceived differences in the diagnostic, therapeutic, and medico-legal utility of all three SPC procedures. Importantly, SPC procedures were shown to have a multifaceted potential for detrimental outcomes for patients and practitioners. Conclusions: Until now, SPC had represented a poorly understood and remains a questionable clinical practice intervention. Education initiatives are required that alert mental health practitioners to the dangers of SPC for patients and practitioners alike, and to present alternative interventions containing less risk. Keywords: no suicide contracts, suicide prevention contracting, suicide assessment, suicide management, mental health practitioners

Since first mentioned in the psychiatric literature (Ewart, 1967) contemporary suicide prevention contracting (SPC) procedures have largely failed to establish a standard form or a theoretical or conceptual model that clearly articulates the procedure and its implementation (Rudd, Mandrusiak, & Joiner, 2006). Despite this, they continue to be in widespread use (Edwards & Harries, 2007). The Australian Psychology Society (1999), the American Psychiatric Association (2003), and the Australian and New Zealand College of Psychiatry (2004) caution practitioners about the use of SPC, stating that SPC remains untested and its use may be detrimental. Others express the concern that overreliance on SPC may come at the expense of a thorough psychiatric evaluation and an ongoing suicide risk assessment process (Simon, 1999). For example, inexperienced practitioners may view a patient promise, and apparent congruent body language, as some form of guarantee or diagnostic certification (Jacobs, 1992, p. 164). Crisis 2010; Vol. 31(6):290–302 DOI: 10.1027/0227-5910/a000048

The first thorough review of SPC (Stanford, Goetz, & Bloom, 1994) describes three perceived perspectives of SPC: the therapeutic perspective (for example using SPC to initiate a therapeutic alliance; communicate a practitioner’s care and concern; offer levels of patient self-responsibility); the diagnostic perspective (initiating SPC as an adjunct to suicide evaluation); and a medico-legal perspective (using SPC for perceived medico-legal protection in the event of an adverse clinical outcome.) Recent reviews of SPC suggesting widespread use and low training rates in SPC also describe advantages, disadvantages, and alternatives that fall under these perspectives: therapeutic, diagnostic, and medico-legal (Davis, Williams, & Hays, 2002; McConnell Lewis, 2007; Miller, 1999; Range, 2005; Weiss, 2001). Using these three perspectives as descriptive categories, the present study sought to detail a profile of SPC and to analyze the inherent problems of SPC when activated, ir© 2010 Hogrefe Publishing

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respective of its effectiveness. Given the concerns above, rather than addressing the substantial ethical and methodological issues with establishing the empirical effectiveness of SPC (assigning potentially hundreds of patients to achieve enough statistical power into groups without/with SPC), the present study sought to build on the existing literature to develop further insight into the potential detrimental effects of SPC.

psychologists, and medical officers. These practitioners were chosen for their anticipated high frequency in assessing suicidal patients and, therefore, increased potential for SPC use. In addition, as the study aimed to understand injudicious use of SPC, establishing a potential to cause harm, the study sought to draw upon experiences from the range of professional disciplines practicing in mental health settings.

Effectiveness of SPC

Instrument

There is conflicting empirical evidence on the effectiveness of SPC in reducing a patient’s risk for suicide. On the one hand, Jones, O’Brien, and MacMahon (1993) found a form of suicide prevention contingency planning was associated with a decrease in self-destructive behavior among adolescent inpatients. Potter, Vitale-Nolen, and Dawson (2005) and Drew (2001) reported SPC with adult inpatients has been associated with an increase in positive and more frequent communication between patient and practitioner. On the other hand, researchers have shown that service users perceive SPC as practitioner self-protection (Decant & Range, 1997). Those surveyed following a suicide crisis felt less able to voice suicidal ideation when assigned to SPC (Farrow, Simpson, & Warren, 2002). Davis et al. (2002) found hospitalized patients with a history of suicidality were less positive about the supportive benefits of SPC than were patients with a limited, or no history of suicidality. Moreover, and compounding issues of the appropriateness of SPC, Drew (2001) has suggested that SPC is offered to higher risk patients. Building on the existing literature, the present study sought to determine any association between risk levels and use of specific SPC procedures.

From a survey of the literature and clinical observation, it was established that there were several SPC procedures used by practitioners. Utilizing a semistructured interview format, this proposition was initially explored with a volunteer sample of twelve practitioners. Based on the information thus gained, a 12 page, 61 item, self-report questionnaire was drawn up in consultation with practitioners from the public mental health services to inquire about their experiences with three SPC procedures. Section 1 of the questionnaire presented definitions of the three SPC procedures. Section 2 sought to understand participants’ level of training in suicide prevention, SPC, and the frequency of specific clinical practice responsibilities. The next three sections contained questions about participants’ use of, attitude toward, and satisfaction with three specific SPC procedures, including questions used in other studies (Davidson, Wagner, & Range, 1995; Mahrer, 1993). The final section comprised requested sociodemographic information. An open-ended question was included, asking for the theoretical and philosophical reasons why other practitioners use SPC.

Defining SPC Procedures

Purpose of the Study The study sought (1) to develop a profile of SPC among a cohort of mental health practitioners operating across a state public mental health service, and (2) to determine factors leading to SPC not being used judiciously, establishing a potential to cause harm.

Method Participants All mental health clinicians practicing in adult, older adult, child and adolescent, inpatient, and outpatient settings in an Australian state public mental health service were invited to participate (N = 1347). The population included clinical psychologists, consultant psychiatrists, mental health nurses, social workers, occupational therapists, counseling © 2010 Hogrefe Publishing

Data was gathered relating to three predefined SPC procedures: (1) no-suicide assurances (NSAs) – a brief verbal exchange a (single question and answer) where a patient is asked to assure the evaluator they are able to 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 time period. Safety strategies are agreed upon that each party will undertake in a suicidal crisis. (3) no-suicide contracts (NSC) – a written document usually co-signed with a copy retained by both the patient and practitioner stating that the patient has agreed to refrain from suicidal behavior, often for a specific time period. Safety strategies are also included.

Procedure The Human Ethics Committee of the University of Western Australia granted ethics approval for the study. Participant Crisis 2010; Vol. 31(6):290–302

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consent was implied by the return of the questionnaire. All clinicians were mailed a letter requesting their participation in the study, a questionnaire, information sheet, and a selfaddressed stamped envelope. Replies were anonymous. After 2 weeks, a series of three reminder letters were sent at 2-week intervals. Of the multivariate tests to determine any main effects and interaction between those who use both NSAg and NSC (with or without the additional use of NSAs), a series of MANOVA tests were employed using the “R” statistical programming language (Ihaka & Gentleman, 1996). The accompanying ranked F statistics and mean scores from univariate ANOVA results have been used to indicate the variable(s) responsible for any reported significance. Pillai’s Trace was used as the test statistic because that has been shown to be most robust to violations of the assumption of multivariate normality and equal variance covariance matrices (Olson, 1976). Data were also analyzed through the Statistical Package for the Social Sciences using frequencies, cross-tabulations χ2 statistics tests for differences in proportions of variables, with associated Cramer’s V statistics presented for correlated data indicating effect size. Wilcoxon matched-pairs signed-ranks tests were performed on data to determine perceived differences between the applications of SPC procedures. Thematic analysis described by Boyatzis (1998) was employed to analyze the narrative comments received from the open-ended question.

assessment as their most frequent practice responsibility, followed by individual psychotherapy (n = 70, 18%), practical support (n = 14; 4%), supportive counseling (n = 48; 13%), crisis assessment (n = 32; 8%), management (n = 17; 4%), and psychological assessment (n = 15; 4%).

Exposure to Suicidality Most participants (n = 260/353; 73.6%) had been exposed to more than five suicidal patient presentations in the previous year. Of these, more than one-third (n = 129; 36.5%) had seen more than 20 suicidal patients in the previous year.

Training A majority of participants (n = 279/399; 70%) had received general suicide prevention training, with less than one-third (n = 117/385; 30%) trained in the use of SPC. Training in SPC was defined as one or more lectures, workshops, seminars, or other similar format. Training status was a significant factor in the utilization of SPC: nonuse of NSAs and no SPC training χ² (df = 1, n = 386) = 4.825, p ≤ .05, Fisher’s exact p = .032, V = .11; nonuse of NSAg and no SPC training χ² (df = 1, n = 386) = 9.608, p ≤ .01, Fisher’s exact p = .002, V = .15; use of NSC and general suicide prevention training χ² df = (1, n = 394) = 9.732, p ≤ .01, Fisher’s exact p = .002, V = .15; nonuse of NSC and no SPC training χ² (df = 1, n = 386) = 17.629, p ≤ .001, Fisher’s exact p = .000, V = .21 (Table 1).

Results Response Rates A total of 445 questionnaires were returned, of which 420 were useable (overall return rate = 31%). For clinical psychologists, the response rate was 54/131 (41.2%), consultant psychiatrists 37/99 (37.3%), social workers 61/171 (35.6%), mental health nurses 207/725 (28.5%), occupational therapists 28/100 (28%), counseling psychologists 10/36 (27.7%), and general medical physicians 23/81 (27.1%).

Demographic and Primary Clinical Responsibilities Participants represented an experienced cohort with a combined years of service mean score of 16.58 years (SD 9.7; range 1 to 44 years). Of these, 342 participants were practicing in a metropolitan health region; 231 (56%) were female. When surveyed, the majority (n = 231; 54%) of participants were working in community outpatient settings, with over one-third (n = 152; 37%) based in inpatient settings. Some 344 (82%) participants were practicing in adult patient settings. A total of 131 (34%) participants described psychiatric Crisis 2010; Vol. 31(6):290–302

Table 1. Utilization of SPC procedures by practitioner’s training status Training type

Use NSAg

Use NSC

Use NSAs

Yes % No %

Yes % No %

Yes % No %

Trained

78.1

62.3

79.3** 20.7

70.7

62.7

Not trained

28.2

37.5

64.2

29.3

37.3

Total

n = 298 n = 96 n = 140 n = 254 n = 335 n = 59

SP training 35.8

SPC training Trained

34.5

17.7

Not trained

65.5

82.3** 23.1

43.7

56.3

32.5

76.9*** 67.5

18.3 81.7*

Total n = 290 n = 96 n = 135 n = 251 n = 326 n = 60 Note. Row percentages reported. SP = suicide prevention. ***p ≤ .001, **p ≤ .01, *p ≤ .05 (two-sided).

Use of SPC Procedures Most participants (n = 355/417; 85%) had used NSAs, with a similar rate of use (n = 317/416; 76%) for NSAg, less so (n = 154/417; 37%) for NSC. In the previous year, just under one-half (157/348; 45%) used NSAs more than 50% of the time when consulting a suicidal patient; less so for NSAg (113/310; 36.5%) and NSC (22/153; 14.5%). © 2010 Hogrefe Publishing


Table 2. Use of SPC procedures by discipline groups

Suicidal Behavior and Exposure to NSAg and NSC

Practitioner, n (%) Medical practitioners

Mental health Allied health nurse practi- practitioners tioners

n = 60

n = 204

n = 149

All

19 (31.5)

82 (40)

36 (23.5)

NSAs and NSAg

22 (36.5)

73 (35)

56 (36.5)

NSAs and NSC

1 (2.7)

5 (2.5)

2 (1.5)

NSAs only

10 (1.5)

15 (7.0)

33 (21.5)

NSAg and NSC

–

2 (0.4)

2 (1.5)

6 (3.0)

8 (5.0)

2 (0.4)

3 (2.0)

19 (9.0)

11 (7.0)

Procedures

NSAg only NSC only None

4 (6.5) – 4 (6.5)

293

Some 129 (n = 129/292; 44%) participants recalled a serious attempt or completed suicide when using NSAg. This rate was higher (n = 167/277; 60%) when not using NSAg. One-third (n = 49/147; 33%) recalled a serious attempt or completed suicide when using NSC, with a higher perceived rate (n = 87/138; 64%) when not using NSC.

Reasons for Using NSAs

Table 2 presents the frequency of using specific SPC procedures according to discipline groups. Overall, community-based allied health practitioners were very highly significantly more likely than medical and nurse practitioners to use NSAg χ2 (df = 1, n = 149) = 14.14, p ≤ .001; Fisher’s exact p = .000, Cramer’s V = .30.

Nonuse of SPC Procedures A cohort of participants (n = 34/416; 8.3%) described never using any of the three SPC procedures. They had the longest years of service mean score (M = 19.91, SD 9.091 vs. M = 16.58, SD 9.704) compared to the total sample. In their qualitative responses these nonusers described a lack of evidence of effectiveness, ethical concerns, no medico-legal benefit, SPC offering practitioners a false sense of security, and access to other proven alternatives as reasons why SPC are potentially detrimental.

Just over one-half (n = 182/352; 51.7%) of participants often to always used NSAs to “assist the therapeutic process” (M = 3.50, SD 1.04; 1 = never to 5 = always), with 14.5% (n = 51) stating they rarely to never used NSAs for this reason. More than one-half (n = 194/350; 55.4%) reported they often to always used NSAs for “medico-legal protection” (M = 3.48, SD 1.33), with 22% (n = 77) stating they rarely to never used NSAs for this reason. Nearly twothirds (n = 212/354; 60%) reported they often to always used NSAs for “diagnostic clarification” of suicide risk (M = 3.66, SD 1.119), with 13% (n = 46) stating they rarely to never used NSAs for this reason. Participants significantly favored NSAs over NSAg for “assessing suicide risk” (Wilcoxon signed ranked test n = 140, z = –3.33, p = .001, twotailed); NSAs: M = 3.68, SD = 1.03; NSAg: M = 3.45, SD = 1.05: 1 = never to 5 = always).

Reasons for Using NSAs (Discipline) Over three-quarters (n = 32/37; 86.4%) of consultant psychiatrists often to always used NSAs to assist the therapeutic process (M = 3.47, SD 1.04; 1 = never to 5 = always). The use of NSAs for supporting the therapeutic alliance was the only item, across the three SPC procedures where consultant psychiatrists had larger positive percentage scores than the other professions.

Utilization and Length of Service Practitioners with less than 5 years experience used more NSAs and were significantly more likely χ2 (df = 9, n = 297) = 26.06, p ≤ .01, p = .002, V = .17) to have used NSAg in the previous year (Table 3).

Dimensions of NSAg and NSC Practitioners were asked to describe the dimensions of SPC procedures. For the six dimension items of NSAg, Cronbach’s α was 0.66 and 0.81 for NSC. Table 4 presents de-

Table 3. Suicidal patients seen in previous year afforded a SPC procedure by practitioner’s length of service status SPC procedures, n (M) SDa Length of service

NSAs

Less than 5 years

57 (2.63) 1.31

NSAg 43 (2.74) 1.25**

14 (1.64) 1.15

NSC

Between 6 and 10 years

67 (2.15) 1.22

61 (2.20) 1.16

29 (1.79) 1.69

Between 11 and 20 years

93 (2.31) 1.30

89 (1.96) 1.10

49 (1.27) 0.63

More than 20 years 16 (2.18) 1.22 104 (2.03) 1.14 55 (1.49) 0.99 Note. aMean and standard deviation for each item; 1 = between 0% and 25% of the time to 4 = between 76% and 100% of the time. **p ≤ .01. © 2010 Hogrefe Publishing

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Table 4. Dimensions – NSAg and NSC Dimensions

n

M (SD)

Table 5. Difference in Dimensions – NSAg and NSC a

b

% often (% rarely)c

NSAg Specify suicidal behaviors 313 cease

2.89 (1.34)

33.8 (42.8)

Set a time period for review

3.83 (1.13)

67.1 (11.8)

313

Mean scoresa Dimensions

F statistic

CraNSAg NSC mer’s V

Specify behaviors to cease

9.02

0.18

2.94

3.20**

Specify alternative behaviors

4.11

0.10

4.39*

4.24

Set time period for review

1.03

0.05

3.93

4.01

0.20

0.02

3.27

3.24

0.01

4.20

4.22

Specify alternatives to suicide

314

4.51 (0.72)

92.4 (1.3)

Specify contacting clinician if suicidal

Include crisis telephone numbers

312

4.37 (1.05)

84.0 (7.7)

Include crisis telephone numbers 0.03

Contact clinician prior to suicide

312

3.43 (1.20)

46.2 (18.6)

Provide clinicians telephone number

314

1.61 (1.23)

10.6 (83.1)

Provide clinicians telephone 0.02 0.00 1.48 1.49 number Note. aMean for each item; 1 = never to 5 = always. aParticipants using no suicide agreements and no suicide contracts (with or without the additional use of no-suicide assurances). **p ≤ .01, *p ≤ .05.

NSC Specify suicidal behaviors 154 cease

3.13 (1.63)** 41.9 (38.3)

Set a time period for review

154

4.10 (1.18)

Specify alternatives to suicide

154

4.32 (1.03)

85.1 (3.9)

Include crisis telephone numbers

154

4.33 (1.20)

80.5 (9.1)

Contact clinician prior to suicide

153

3.33 (1.38)

41.2 (22.3)

NSAg

72.1 (5.8)

Provide clinicians 152 1.60 (1.41) 9.0 (85.5) telephone number Note. aMean and standard deviation for each item; 1 = never to 5 = always. b% often = percentage of participants responding 4 = often and above. c% rarely = percentage of participants responding 2 = rarely and below. **p ≤ .01.

scriptive data relating to the emphasis participants gave to specific dimensions in either SPC procedure. Participants using all three SPC procedures in their career significantly favored NSC (Wilcoxon signed ranked test n = 144, z = –2.63, p = .009, two-tailed) over NSAg when requesting a patient to “cease specific suicidal behaviors.”

Differences in Dimensions, Reasons for Use, and Opinion Toward NSAg and NSC For the analysis, 105 participants were selected who had used NSAg and NSC and for whom complete data were available. An overall two-way unreplicated MANOVA was performed comparing responses from participant’s use of NSAg (with or without the additional use of NSAs), and use of NSC (with or without the additional use of NSAs). The multivariate main effect was significant between instruments (Pillai’s Trace (df = 1, 105) = 0.568, p = .0002 V = .16). To clarify how these participants perceived differences between the NSAg and NSC an additional three MANOVA tests were conducted with related subsets of items in the questionnaire that measured subjects: Crisis 2010; Vol. 31(6):290–302

Table 6. Reasons for use – NSAg and NSC NSC a

SD

n

Ma

SD

n

M

Provide alternatives to suicide

312

4.10 0.90 115

4.05 1.15

Increase patient selfresponsibility

312

3.95 0.90 115

3.98 1.03

Increase patient sense of safety

312

4.00 0.92 115

3.88 1.20

Therapeutic

Medicolegal Increase legal protection

312

3.54 1.30 154

3.29 1.52

Abide by superiors’ request 308

2.32 1.43 155

2.60 1.72

311 Lack resources (i.e., inpatient care, psychiatric review, senior consultation)

2.70 1.31 154

2.93 1.47

Diagnostic Evaluate inpatient vs. outpatient care

312

3.50 1.19 155

3.32 1.45

Assess suicide risk

313

3.46 1.19 155

3.21 1.45

Assess precipitating risk 308 2.90 1.24 154 3.05 1.65 factors Note. aMean and standard deviation for each item; 1 = never to 5 = always.

1. emphasis given to the specific dimensions of NSAg and NSC 2. reasons for use of NSAg and NSC 3. opinion of the helpfulness of NSAg and NSC For the nine reasons for use items (Table 6) Cronbach’s α was 0.80 for NSAg and 0.88 for NSC. For the 16 attitude items (Table 8) Cronbach’s α was 0.88 for NSAg and 0.92 for NSC. The emphasis given to specific dimensions between NSAg and NSC was significant (Pillai’s Trace (df = 1, 105) = 0.140, p = .0173 V = .16). Table 5 presents the accompanying univariate effects comprising ranked F values and mean score for each dimension. © 2010 Hogrefe Publishing


295

Table 7. Difference in reasons for use – NSAg and NSC Mean scoresa

procedures

F statis- CraNSAg tic mer’s V

NSC

Therapeutic Increase patient sense of safety 3.66

0.10

3.93

3.79

Provide alternatives to suicide 1.48

0.06

4.02

3.93

Increase patient selfresponsibility

0.09

0.01

3.94

3.92

14.01

0.20

3.42*** 3.13

Lack resources (i.e., inpatient 2.54 care, psychiatric review, senior consultation)

0.09

2.74

2.87

Abide by superiors request

1.33

0.05

2.51

2.44

Evaluate inpatient vs. outpatient care

4.93

0.13

3.32*

3.13

Assess suicide risk

4.70

0.13

3.32*

3.13

Medicolegal Increase legal protection

Figure 1. SPC use-by-risk curve. The data indicate that the perceived differences in the dimensions of NSAg and NSC is largely expressed in “specifying behaviors to cease” (F = 9.02), with participants perceiving NSC significantly more suited to achieving this outcome. NSAg were perceived to be significantly more suitable when “specifying alternative behaviors to suicide” (F = 4.11).

Diagnostic

Assess precipitating risk 0.01 0.00 2.87 2.88 factors Note. aMean for each item; 1 = never to 5 = always. aParticipants using no suicide agreements and no suicide contracts (with or without the additional use of no-suicide assurances). ***p ≤ .001, *p ≤ .05.

SPC and Suicide Risk Several of the findings make conceivable the presence of a “use by risk” phenomena. Most participants (n = 355/417; 85%) used NSAs significantly more than NSAg for “assessment of suicide risk”; NSAg were used significantly more when “specifying alternatives to suicide”; whereas NSC were used significantly more when “specifying behaviors to cease” (see Table 4 and Table 5). These data indicate a potential clinical practice situation where (1) NSAs represent “a general assessment intervention” for all patients, (2) NSAg represent “a specific intervention” suggesting alternatives to suicidal behavior, and (3) NSC are perceived to offer practitioners a “specialized intervention” aimed at deterring specific suicidal behaviors with the highest risk patients (Figure 1).

Therapeutic Perspective of NSAg and NSC When asked to describe their reason for using NSAg and NSC for three specific therapeutic outcomes, participants were generally positive regarding the capacity of either procedure to affect the therapeutic outcome (Table 6). A majority of participants (n = 250/312; 80.1%) often to always used NSAg more when suggesting alternatives to suicidal behavior than NSC (n = 113/155; 72.9%). A second two-way unreplicated MANOVA test found a significant difference within these participants’ use of NSAg and NSC (subset 2), Pillai’s Trace (df = 1, 105) = 0.223, p = .002 V = .17 (Table 7). Across 15 of 16 opinion items (Table 8), participants © 2010 Hogrefe Publishing

were generally more positive regarding the therapeutic features of NSAg over NSC. In one item, participants felt NSC were superior to NSAg for severely suicidal patients. A majority of participants agreed to strongly agreed NSAg reduced suicide risk (n = 188/310; 60%), reduced legal liability risk’ (n = 135/314; 42.9%), and strengthened a therapeutic relationship (n = 222/314; 70.7%). Less than 10 percent (n = 24/314; 7.6%) agreed to strongly agreed NSAg weaken a therapeutic relationship, with n = 49; 15.6% undecided. Significant differences were also found across these 16 opinion items (subset 3) among those who use both NSAg and NSC (Pillai’s Trace (df = 1, 105) = 0.256, p = .025 V = .13). With regard to participants’ perceptions of the therapeutic advantages, NSAg were perceived as significantly more helpful than NSC with children and adolescents, those mild to moderately suicidal, and in communicating their care and concern (Table 9).

Medico-Legal Perspective of NSAg and NSC Participants were asked three questions relating to their use of NSAg and NSC to improve their medico-legal status in the event of an adverse clinical outcome (see Table 6). The majority of participants (n = 173/312; 55.5%) often to always used NSAg for medico-legal protection, less so for NSC (n = 74/154; 48%), and to abide by a superiors request to use NSAg (n = 60/308; 19.5%). However, participants used NSC more when lacking suitable resources for reCrisis 2010; Vol. 31(6):290–302

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Table 9. Difference in opinion items – NSAg & NSC

Table 8. Opinion items – NSAg and NSC NSAg

Mean scores a

NSC a

SD

n

a

M

F Sta- Cra- NSAg NSC tistic mer’s V

SD

n

M

Helpful with youth aged 13 to 19 years

301

2.64 1.05 152

2.90 1.16

Helpful with mildly suicidal patients

314

2.00 0.89 155

2.18 1.15

Helpful with youth aged 13 to 19 10.37 0.12 years

(2.40**(2.57

Helpful with moderately suicidal patients

314

2.19 0.96 154

2.30 1.18

Helpful with mildly suicidal patients

10.07 0.15

(1.90**(2.12

Helpful with children < 12 years

297

3.36 1.05 149

3.59 1.35

Helpful with moderately suicidal patients

6.67 0.12

(2.05* (2.23

Communicate care and concern

312

2.06 0.82 155

2.21 1.14

Helpful with children < 12 years

4.96 0.10

(3.24* (3.38

Communicate care and concern

4.04 0.08

(1.95* (2.07

Helpful with adults > 20 years

309

2.17 0.92 155

2.31 1.24

Helpful with adults > 20 years

3.34 0.07

(2.08

(2.18

Reduce risk for suicide

1.60 0.05

(2.46

(2.53

Therapeutic Therapeutic

Reduce risk for suicide

310

2.47 0.88 155

2.60 1.16

Weaken a therapeutic relationship

0.77 0.04

(3.78

(3.84

Weaken a therapeutic relationship

314

3.83 0.82 155

3.90 0.95

Helpful with severely suicidal patients

0.70 0.05

(3.17

(3.10

Helpful with severely suicidal patients

312

3.22 1.24 154

3.18 1.41

Give patient sense of security

0.10 0.01

(2.16

(2.18

Give patient sense of security

311

2.24 0.83 155

2.30 1.12

Strengthen a therapeutic relationship

0.02 0.00

(2.20

(2.21

Strengthen a therapeutic relationship

314

2.33 0.89 155

2.34 1.13

Helpful with chronically suicidal patients

0.01 0.00

(2.93

(2.92

Helpful with chronically suicidal patients

312

2.88 1.12 155

2.92 1.34

Offer clinician a sense of security

313

2.50 1.03 155

2.59 1.42

Helpful with older adults over 65 years

312

2.55 0.94 154

2.61 1.11

Medicolegal Reduce recriminations from peers

311

2.92 1.17 154

3.11 1.32

Reduce legal liability 314 2.94 1.18 151 2.98 1.24 Note. aMean and standard deviation for each item; 1 = strongly agree to 5 = strongly disagree.

sponding to suicide risk (n = 47/154; 30.5%; NSAg n = 89/311; 28.6%). As noted, the multivariate main effect for reason for use between participants using both NSAg and NSC was significant, Pillai’s Trace (df = 1, 105) = 0.223, p = .002 V = .17. This was accompanied by a significant univariate effect (see Table 7), where NSAg were significantly favored (F = 14.01) over NSC for “increasing legal protection.” Some difference was found between participants’ reason for use favoring NSC over NSAg when “lacking resources” to respond to suicide risk.

Diagnostic Perspective of NSAg and NSC The majority of participants (n = 163/313; 52%) often to always used NSAgfor assessing suicide risk and to evaluate the need for inpatient or outpatient care (n = 168/312; Crisis 2010; Vol. 31(6):290–302

Offer clinician a sense of security

0.01 0.00

(2.50

(2.50

Helpful with older adults over 65 years

0.00 0.00

(2.50

(2.50

0.00 0.00

(3.10) (3.10)

Medicolegal Reduce recriminations from peers

Reduce legal liability 0.018 0.00 (3.00) (3.01) Note. aMean for each item; 1 = strongly agree to 5 = strongly disagree. a Participants using no suicide agreements and no suicide contracts (with or without the additional use of no-suicide assurances). **p ≤ .01, *p ≤ .05.

53.8%). However, participants used NSC more when assessing precipitating risk factors (n = 51/154; 43.1%) (see Table 6). Perceived differences between the diagnostic aspects of NSAg and NSC were expressed in evaluating types of care (F = 4.93) and assessment of risk (F = 4.70) (see Table 7). Unsurprisingly, community-based participants were very highly significantly more likely to utilize NSAg as a dispersal procedure χ2 (df = 4, n = 310) = 41.00, p ≤ .001, p = .000, V = .36) than the inpatient cohort.

Discussion The professional discipline and gender distribution of the sample was considered adequately representative of mental health practitioners in the public mental health services of Australia. While the response rate of 31% necessarily means generalizability is significantly limited, findings are generally consistent with and replicate/ cross validate find© 2010 Hogrefe Publishing


ings from previous studies. In terms of external validity of the findings there was a greater distribution (49.2%) of nurses. A practitioner’s discipline has been found to be a significant demographic predictor for using SPC procedures (Page & King, 2008). Hence, it is possible that some of the results do not generalize to specific professions. Importantly, however, while the study sought responses from five professional groups, it was less concerned with individual discipline specific profiles. Rather, it sought to establish a profile, highlighting – irrespective of practitioner demographics – the inherent potential problems with SPC when activated.

Profile of SPC A unique aspect of the present study is the differentiation between NSAs, NSAg, and NSC regarding reasons for use and opinion of perceived effectiveness. Studying three, rather than one SPC procedure, as most previous studies have done, allowed for a far deeper understanding of SPC, assisting to establish a detailed profile, and a potential to cause harm profile.

Usage Consistent with previous studies (Mahrer, 1993; Miller, Jacobs, & Gutheil, 1998; Page & King, 2008) a majority of those surveyed had used NSAg and most had used them in the past year. All of the five surveyed professions had used SPC procedures (Drew, 2001; Kroll, 1998, 2000; Page & King, 2008; Sanders, Ting, Power, & Jacobson, 2006). That participants generally preferred verbal over written SPC procedures is supported by previous findings (Kroll, 2000; Mahrer, 1993; Page & King, 2008).

Use of NSAs It is apparent that a proportion of participants have likely reinterpreted the presented definition of NSAs. The low routine frequency of using NSAs (45% using NSAs more than 50% of the time) runs counter to clinical judgment that NSAs are a routine procedure, representing an adjunct to risk assessment modalities. A possible explanation for the low rate can be found in the finding that an experienced (M = 19.5 service years) cohort of practitioners (n = 34) reportedly used none of the SPC procedures. In this instance, it is conceivable these practitioners routinely use a brief verbal exchange (single question and answer) where a patient is asked to assure them they are able to refrain from suicidal behavior. However, they do not perceive them as NSAs. Support for this premise is found in the literature where suicidology is seen to suffer from unclear nomenclature (Maris, 2002, p. 319; O’Carroll et al., 1996). Specific to SPC, with no established standard form or conceptual mod© 2010 Hogrefe Publishing

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el (Potter et al., 2005, p. 145; Rudd et al., 2006, p. 245), practitioners are largely left to construct a SPC procedure, giving different emphasis to specific dimensions and use of conceptual language.

Training Consistent with previous findings, formal SPC training rates were around 30% (Mahrer, 1993; Miller et al., 1998) suggesting in vivo learning is the predominant mode for practitioners to gain an understanding of SPC, its indications and contra-indications (Miller, 1999). A recent Canadian study by Page and King (2008) reported a training rate of 57%, which may indicate increased attention to SPC training in that setting. The impression that SPC is used by a majority of practitioners without formal training (Miller et al., 1998, p. 80) is not sustained by the findings. While the present findings demonstrate significant associations between use/training and nonuse/no training, there were several untrained cohorts using NSAg and NSC. Mahrer’s (1993) study demonstrated training was associated such that practitioners used SPC judiciously and were more likely to undertake an individual evaluation for the appropriateness of SPC. The use of NSAg and NSC without training is, therefore, concerning.

SPC and Suicidality Consistent with previous findings (Kroll, 2000; Page & King, 2008), practitioners reported serious attempts and suicides when using SPC procedures. In the present study, the number of participants recalling a serious attempt or completed suicide when using NSAg (44%) and NSC (33%) were similar to the rates reported by Page and King (2008) (31.4%) and Kroll (2000) (41%). Without empirical evidence of effectiveness for SPC, these current data are suggestive that the greater number of years in practice increases the likelihood of exposure to serious attempts and suicides (Kroll, 2000) irrespective of the presence of SPC being in place. Nevertheless, it would be unwise to discount absolutely any benefit in an extended and detailed discussion with a patient regarding steps to take when suicidal urges arise.

Use and Risk Consistent with previous commentary (Davis et al., 2002, Drew, 2001; Farrow et al., 2002), the present findings make it conceivable that NSC are offered to relatively higher risk patients. There appears to be a paradoxical situation where NSC represents an apparently specialized intervention aimed at “deterring specific suicidal behaviors,” without Crisis 2010; Vol. 31(6):290–302

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data attesting to its validity, efficacy, or potential to cause harm. This interpretation of the less therapeutic and more deterrent nature of written NSC is somewhat contrary to prior expert-opinion where the written procedure is seen to act as an aide-mémoire for detailing alternative behaviors (Mahrer & Bongar, 1996; Range, 2005). Delineating between the verbal and written procedure is seen as a possible a reason for the difference.

Use and Experience Present findings are also consistent with Mahrer (1993) and Kroll (2000) who found what has been described as “a time by use curve” (Mahrer, 1993, p. 111), whereby exposure to suicidality initially increases SPC use. However, a threshold point is reached over time with proportional usage decreasing. In the present study, practitioners with less than 5 years of practice experience used more NSAs and were more likely to use NSAg. However, with the exception of NSAs, the overall frequency of utilizing NSAg and NSC decreased after 11 years of service, which may approximate the so-called threshold point.

Use and Discipline Consistent with previous findings (Page & King, 2008) nonmedical practitioners were significantly more likely to use SPC. A medical practitioner’s specialized training and admission rights to inpatient care may account for this.

were seen to be significantly more appropriate for youth and those at a mild to moderate risk for suicide.

Medico-Legal In the present study, practitioners were using SPC procedures on average 50% of the time as a preemptive defensive (medico-legal) intervention. The use of SPC for self-protection has also been reported by practitioners in Canada, North America, and New Zealand (Davidson et al., 1995; Farrow, 2002; Mahrer, 1993; Page & King, 2008; Sanders et al., 2006). By differentiating between NSAg and NSC, the study demonstrated the apparent use of NSC as “a stop-gap measure” when practitioners lack the resources to adequately respond to suicide risk. Farrow (2002, p. 216) found a similar use of SPC generally with crisis nurses. The emphasis placed on NSC for this reason may relate to some practitioners perceiving the written procedure as a specialized intervention. The intriguing finding of practitioners significantly favoring verbal NSAg over written NSC to increase their legal protection is somewhat counterintuitive to the notion of being better protected by having documented evidence. Here, an amalgam of explanatory contextual factors may comprise (1) NSAg being generally favored over NSC (2) abiding by good practice by documenting patient responses in medical notes.

Diagnostic Therapeutic In all but three items (“help with severely suicidal,” “lack resources,” and “assessing precipitants to suicide”) NSAg were used and positively endorsed more than NSC. Here, the general finding that practitioners prefer verbal over written SPC procedures was consistent with prior studies (Kroll, 2000; Mahrer, 1993; Page & King, 2008). On average, 70% of participants felt that NSAg and NSC are unlikely to weaken a therapeutic relationship, being somewhat lower (80%) than reported by Page and King (2008) and Davidson et al. (1995). In the present study, the central theme of SPC “communicating a practitioner’s care and concern” is consistent with previous findings (Davidson et al., 1995; Mahrer, 1993; Page & King, 2008). These findings are also consistent with the psychiatric literature elsewhere that postulates the utility of SPC in positively affecting a therapeutic alliance (Gutheil, 1992; Miller et al., 1998; Range, 2005; Stanford et al., 1994). While the general principle was consistent with prior studies (Davidson et al., 1995; Mahrer, 1993) the present study found that verbal NSAg, but not the written NSC, Crisis 2010; Vol. 31(6):290–302

The frequency in participants using SPC for assessing suicide risk and evaluating the need for inpatient or outpatient care is similar to those reported elsewhere (Mahrer, 1993). Overall, participant responses indicate verbal SPC procedures are perceived as a more inherently sensitive assessment. In practice, however, despite more than a dozen studies on SPC, none have proved that any SPC procedure is an effective risk assessment tool (Rudd et al., 2006, p. 246).

Potential to Cause Harm Profile of SPC Usage Some have suggested that, in general, SPC is used by less experienced practitioners (Kroll, 2000; Mahrer, 1993). The present findings support this contention for NSAg usage. These findings indicate that as mental health practitioners gain more experience and knowledge – likely developing a perceived suite of effective clinical practice interventions for specific presenting problems – the perceived effectiveness of SPC diminishes. © 2010 Hogrefe Publishing


Medico-Legal Kroll (2000) suggests that US psychiatrists were using SPC procedures despite reporting that they found them not to be helpful. Consistent with this observation, the present study found a disparity between practitioners’ reasons for use (Table 6) and related opinion data (Table 8): using SPC for legal protection despite believing they hold little protective benefit. Similarly, Farrow et al. (2002, p. 214) found crisis nurses felt their assessment alone would not be seen as sufficient in cases of adverse outcomes. Here, there is a potential clinical practice situation where some practitioners see SPC as compellingly and obviously beneficial, leaving other practitioners at risk of being seen as negligent when not employing these procedures. The importance of the debate regarding the appropriate utilization of SPC cannot be underestimated when SPC is seen to be used increasingly in lieu of a working therapeutic alliance (Goin, 2003; Kroll 2007). It is also important in the light of reports of adverse clinical outcomes related to the over reliance on SPC (Potter et al., 2005; Stanford et al., 1994) and when practitioners are being censured by professional associations for failing to obtain a no-suicide contract (Kroll, 2007). With one-half of participants apparently routinely using SPC procedures for perceived practitioner legal protection, there is the potential for SPC to replace or moderate accepted standards of care (e.g., detailed risk assessment, removal of lethal means, senior peer consultation, hospitalization, etc.) (Simon & Hales, 2006, p. 262) and for SPC to be offered when contraindicated (Mahrer, 1993, p. 90). Paradoxically, in both cases, the potential for successful claims of negligence being made against a practitioner are likely increased.

Therapeutic Importantly, the present findings demonstrate that a majority of practitioners appeared not to have fully considered the use of SPC from a patient’s perspective. In fact, a substantial majority of participants positively regarded both NSAg and NSC to enhance a therapeutic relationship. However, few considered the reverse, where, for example, patients may perceive SPC as self-serving (Decant & Range, 1997; Farrow et al., 2002), thereby weakening a therapeutic alliance. Moreover, present results indicate SPC is being offered to those relatively high risk patients (a “use by risk curve” phenomena) who are least likely to be able to give informed consent to the procedure (Farrow & O’Brien, 2003; Page & King, 2008). When several findings from the literature are taken into account, potentially dangerous clinical practice situations can be identified. First, it is conceivable that SPC procedures are offered according to risk status (use by risk curve). Second, patients present more disparate, often negative attitudes than practitioners toward SPC (Davis et al., 2002; Decant & Range, 1997; Farrow et al., 2002). Find© 2010 Hogrefe Publishing

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ings from Davis et al. (2002) suggest that patients with a limited, or no history of suicidal behavior who present a positive attitude regarding SPC may indicate the “right patient type” to use SPC procedures with. Finally, studies indicate no robust prior assessment of appropriateness before employing SPC (Mahrer, 1993; Page & King, 2008). With available research on the detrimental aspects of SPC taken into account, it is indeed plausible that SPC cannot be used without inherent risk. For example: (1). “How does a practitioner accurately individually evaluate what constitutes a ‘limited history’ of suicidal behavior? (2). How does a practitioner accurately evaluate if a patient is truly positively judging an offer for SPC? (3). How can a practitioner prevent a distressed patient’s (including known patients) positive judgments about SPC from changing over time?” None of these situational factors can be adequately addressed by a treating practitioner. The degree of harm generated by activating SPC is proportional to the level to which SPC replaces or moderates accepted standards of care. Moreover, this potentiality is amplified by the degree to which the patient negatively perceives SPC, thereby likely weakening a therapeutic alliance and the future potency of any agreement or contract.

Diagnostic There is an inherent problem with over relying upon SPC with suicidal individuals for evaluating suicide risk. Completed suicide has a low base rate and its prediction is vulnerable to relatively high percentages of false positives (Shaffer, Garland, Gould, Fisher, & Trautman, 1988, p. 676). Hence, activating SPC establishes a situation where practitioners can, over time, perceive practice efficacy in SPC procedures. While NSAs or NSAg may provide enough therapeutic advantage to affect a clinical outcome, the nature of such influence and its magnitude remains unclear.

Alternatives to SPC Several alternatives procedures and techniques have been reported elsewhere (Mahrer & Bongar, 1996; Lee & Bartlett, 2005; Miller, 1999; Miller et al., 1998; Potter et al., 2005; Rudd et al., 2006). In limited circumstances, a specific SPC procedure may be offered without a practitioner establishing a potential for harm that did not exist prior to activating SPC. Where previous studies have largely failed to differentiate between SPC procedures, the present findings provide some evidence allowing for a more sophisticated decision-making process regarding the question: “Should SPC be a standard component of practice (McConnell Lewis, 2007; Page & King, 2008)?” An original finding of the present research is the relative high rate in using NSAs for diagnostic clarification, potentially representing a “standard of care.” An intriguing related finding was that consultant psychiatrists Crisis 2010; Vol. 31(6):290–302

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(representing the most qualified discipline) positively supported, above all else, the therapeutic benefit of NSAs. Therefore, it is plausible that the use of NSAs for gathering a subjective self-reported measure of patient risk for suicidal behavior, and in doing so offering patients a positive expectation message, represents the most compelling reasons for use of any SPC procedure. This may represent the limit of SPCs utility, significantly reducing the potential for harm, and is consistent with expert opinion (Gutheil, Bursztajn, Hamm, & Brodsky, 1983, p. 321; Shea, 1999, p. 207). Importantly, expert opinion citing the perceived advantages of SPC (Miller, 1999; Range, 2005; Stanford et al., 1994; Weiss, 2001) needs to be considered in light of the present and other studies (Davis et al., 2002; Farrow, 2002; Farrow et al., 2002; Kroll, 2000; Page & King, 2008). While these studies are somewhat speculative because of the largely qualitative nature of the evidence, it is arguable that a first order question: “Do the potential inherent risks of SPC outweigh the perceived benefits?” has been answered in the affirmative.

Strength, Limitations, and Future Research This is the first Australian study focused solely upon SPC. The study’s findings derive from the largest sample to date reported internationally and include the range of mental health disciplines. The survey also provided a wealth of other findings that will serve to develop an emerging nomenclature and decision-making schema for SPC. While similar low response rates were realized across the five professions represented, there appear to be several reasons for the low response: the length of the survey (12 pages), and the sensitive subject of the study (Mahrer, 1993) conducted in a risk averse and contested practice setting (in part because of confused lines of accountability and responsibility within these public mental health service teams) (Peck & Norman, 1999, p. 236–267; Rosen, 2001, pp. 133–136). As noted, because of the low response rate, it is possible the “reasons for use” and “opinion” findings do not generalize beyond the study’s sample. The authors also warn against generalizing the findings to practice settings and societal cultures vastly different to that of a typical Western industrialized society (Calucci, Kelly, Minas, Jorm, & Chatterjee, 2010). Subsequent studies may wish to examine SPC within a cross-cultural context, and in private practice. Both settings may reveal differences in reasons for use and factors in conducting a prior assessment of appropriateness.

Conclusion Practitioners consulting in an Australian public mental health service had similar practices and experiences with Crisis 2010; Vol. 31(6):290–302

SPC to that of North American, Canadian, and New Zealand practitioners. The study’s findings support and advance knowledge regarding SPC’s potential to cause harm. As one-half reported a medico-legal reason for usage, with a substantial majority positively endorsing SPC as “causing no harm,” mental health practitioners need to be alerted to their lack of medico-legal protection and the potential to produce detrimental outcomes. The high rates of using SPC procedures for what can be seen as contraindicated reasons indicate that educating mental health practitioners about the advantages, disadvantages, contraindications, and alternatives to SPC is justified.

Acknowledgment The authors express their thanks to Associate Professor Brian McArdle DPhil, Department of Mathematics, University of Auckland, for his statistical analysis assistance. Especial thanks also to the four anonymous referees for their timely comments and to Dr. Natalie J. Edwards PhD, Massey University, New Zealand for reviewing drafts of the manuscript.

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About the authors Mark Sachmann, PhD, is an Assistant Professor at The University of Western Australia. He also runs a private psychoanalytic practice in Perth. His research interests focus on developing risk factor models for the etiology of personality disorders incorporating early childhood trauma experiences and genetic temperamental vulnerabilities. Crisis 2010; Vol. 31(6):290–302

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Stephen J. Edwards, PhD, is a Research (Honorary) Fellow at the University of Western Australia, a former Clinical Director at Lifeline Aotearoa (New Zealand), and is currently a Mental Health Clinician/Senior Social Worker with North Metropolitan Area Health Services, Mental Health in Perth, Australia. The study and its first author are the recipient of several awards including a Pfizer Australia – Best New Research Award (Poster) and a Developmental Research Award presented by the Whitfeld Fellowship Committee at The University of Western Australia.

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Stephen J. Edwards University of Western Australia Mail bag 256 Nedlands Western Australia 6009 E-mail [email protected]

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