No-Suicide Contracts with Suicidal Youth: Mental Health Professionals' Perceptions and Current Practice

By Hansen, Andrea; Heath, Melissa Allen et al. | Contemporary School Psychology, January 1, 2012 | Go to article overview
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No-Suicide Contracts with Suicidal Youth: Mental Health Professionals' Perceptions and Current Practice

Hansen, Andrea, Heath, Melissa Allen, Williams, Marleen, Fox, Jay, Hudnall, Gregory A., Bledsoe, Catherine, Contemporary School Psychology

Commonly used in clinical and medical settings, no-suicide contracts (NSCs) solicit commitment from suicidal individuals not to attempt suicide. The prevalence of community and schoolbased Mental Health Professionals' (MHPs) use of NSCs with suicidal youth (SY) is unknown. Additionally, minimal feedback is available regarding MHPs' current practice and perceptions of implementing NSCs. Likewise, school and agency policy directing intervention with SY is not well described, or clearly understood. Of 326 individuals attending Utah's Annual Youth Suicide Prevention Conference, 243 completed questionnaires (74.5% participation rate) assessing perceptions and current practice related to NSCs. Of these questionnaires, 229 were completed by MHPs who specifically worked with youth under the age of 18 years. These questionnaires were included in data analysis. When intervening with SY, half of participants reported using NSCs. However, only 3.5% of participants (n = 8) reported knowledge of formal written school district or community mental health agency policy that offered guidelines for implementing NSCs. Implications for clearly specifying current policy to guide interventions with SY are discussed.

KEYWORDS: no-suicide contract, child, adolescent, mental health professional, suicide prevention policy.

Worldwide, approximately 3,000 individuals complete suicide daily and approximately 20 times this number of individuals survive suicide attempts (World Health Organization [WHO], 201 1). Annual deaths resulting from suicide exceed the number of deaths from homicides and wars combined (WHO, 2004).

Prevalence of Youth Suicide

For U.S. youth ages 10-24, suicide is the third leading cause of death, each year accounting for approximately 4,400 deaths and 149,000 emergency room visits for attempted suicide (Centers for Disease Control and Prevention [CDC], 2009). Additionally, the prevalence of completed and attempted suicides are underestimated, the cause of injury or death erroneously documented as accidental or subsequent to high-risk activity (e.g., automobile accidents, accidental drug overdoses, falls, drownings). Based on data from the 2009 U.S. Youth Risk Behavior Survey, 13.8% of ninth through 12th-grade students seriously considered attempting suicide in the previous 12 months; 10.9% made a plan to complete suicide; and 6.3% attempted suicide (CDC, 2010, p. 9). From a teacher's perspective - considering these numbers in a high school classroom of 30 students - over the past 12 months, four students seriously considered attempting suicide, three made a plan to complete suicide, and two students attempted suicide.

These numbers reflect the current prevalence of suicidal ideation and planning among youth. Additionally these numbers represent desperate youth contemplating and taking desperate action to escape physical and emotional pain. Voicing medical and mental health professionals' sentiment, Weiss (2001) stated, "The management of the suicidal patient is one of the greatest clinical challenges facing mental health professionals" (p. 414).

An indication of difficulties preceding suicide, over 90% of individuals who completed suicide struggled with depression and/or other forms of mental illness and substance-abuse disorders (National Institute of Mental Health, 2010). Another contributing risk factor for suicide completion is alienation from social support (Cash & Bridge, 2009; Taylor, Gooding, Wood, & Tarrier, 2011). One example of social alienation linked to increased suicide, 63% of all Utah youth suicides were completed by males registered in the juvenile justice system (Moskos, Halbem, Alder, Kim, & Gray, 2007).

Suicide Prevention

Noting the prevalence and impact of youth suicide, medical and mental health professionals (MHPs) identify youth suicide as a major public health problem (Gould, Shaffer, Fisher, Kleinman & Morishaima, 1992; National Institute of Mental Health, 2010; U.

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No-Suicide Contracts with Suicidal Youth: Mental Health Professionals' Perceptions and Current Practice


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