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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
BOX 11–2 Essential Components of a Safety Plan
BOX 11–3 The Issue of No-Suicide Contracts A critical issue that needs to be understood is that of no-suicide contracts, sometimes called safety contracts , a strategy used by some clinicians in the context of a long- term, therapeutic relationship in which the client “promises” to contact the clinician before acting on suicidal ideation. No-suicide contracts are not the same as the devel- opment of a thorough safety plan. Contracting with a client is a controversial and often misused strat- egy (Hoffman, 2013; Shea, 2009). Evidence has not supported the efficacy of this method as a primary intervention (Drew, 2001; Edwards, 2010; Freedenthal, 2013; Rudd et al., 2006). In fact, it may even be counter- productive in clients with borderline or passive-aggressive pathology (Shea, 2009). Such contracts should never be used in short-term encounters with clients, such as in emergency departments or during brief hospital stays, or with clients who are unknown, agitated, psychotic, impul- sive, or under the influence of drugs and alcohol (Hoffman, 2013). They should never be used with the presump- tion that they will deter a client from attempting suicide. Shea adds that if clinicians use a safety contract with the belief that it will be a deterrent to suicide, they should understand that it not only “guarantees noth- ing [but also] may yield a false sense of security” among clinicians (2009, p. 21). The consequential danger is that clinicians may become less watchful or feel less need to reassess the client, thus missing critical signs of increasing suicide risk. Roberts (2020) cites American Psychiatric Association (APA) practice guidelines that advise against using no-suicide contracts independently or outside of a well-established patient-provider relationship. Nurses should avoid no-suicide contracting altogether. Even in the conduct of therapy by a skilled therapist, it should be used with great caution and for limited, specific assessment purposes. In general, it is important to recognize that not all sui- cidal individuals are alike, so interventions should be multifaceted and suicide prevention plans should be comprehensive. Many models and tools for suicide assessment have been developed. One such model, SAFE-T (Suicide Assessment Five-Step Evaluation and Tri- age), summarizes the key elements in suicide assessment (see Box 11–4). Information for Family and Friends of the Suicidal Client The following suggestions are made for family and friends of an individual who is suicidal: ■■ Take any hint of suicide seriously. Anyone express- ing suicidal feelings needs immediate attention.
According to Stanley and Brown (2008, pp. 3–4), the essential components of a safety plan include nursing support and assistance for the following: 1. Recognizing warning signs that precede suicide crises 2. Identifying and employing internal coping strategies that the client can implement without needing to contact additional support people 3. Identifying supportive family members and friends with whom the client can discuss suicide and who may help resolve a potential crisis 4. Identifying people and healthy social settings that the client can use for general support and distraction from suicidal thoughts and urges 5. Identifying resources and contact information for mental health professionals and agencies when needed in an escalating crisis situation 6. Problem-solving with the client ways to reduce the potential for access to and use of lethal means Once the safety plan is elaborated with the client, an evaluation of the appropriateness of the plan and a col- laborative assessment of the likelihood that the client will implement this plan should be conducted. Assessment for suicidal risk and responsive interven- tion must be ongoing, because suicidal ideas and intent may change over hours, days, or longer time periods. The need for revision of the safety plan may become evident. Critical times for reassessment of risk and reevaluation of the safety plan (Hoffman, 2013) include the following: 1. When there is a change in the client’s clinical presenta- tion or worsening of symptoms 2. When medications or treatments are changed 3. When significant others identify an increase in concern 4. When a client stops treatment Single interventions, including hospitalization, med- ication, and no-suicide contracts, are not supported by evidence as being effective in reducing suicides (Jobes, 2015). Clients need to be actively engaged as partners in every step of the assessment and inter- vention process. Evidence does support that early follow-up phone calls with patients who have been treated for a suicide attempt is an effective strategy for reducing suicide risk (Exbrayat et al., 2017; Stan- ley et al., 2018).
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