Safety Contracts in Therapy: Do They Work and What Are the Alternatives?
When you’re in a mental health crisis, it can be incredibly hard to make sound decisions or even fully understand what is happening to you. Yet, there are occasions when individuals experiencing a crisis receive a no-harm contract and are asked to sign it. This is a contract that outlines your promise not to harm yourself. While this practice may have good intentions, good intentions do not necessarily lead to positive outcomes.
There are alternatives to no-harm contracts, such as collaborative crisis intervention, which may be a better option. Understanding safety contracts and their effectiveness in therapy can help individuals and their families advocate for more effective care. Whether you’re working through a crisis yourself or supporting someone you love, understanding what crisis care should be like will help you get the treatment you need and deserve. This article will cover:
- What a safety contract in therapy is.
- The history of no-harm contracts in mental health.
- What research shows about the effectiveness of no-suicide contracts.
- The ethical concerns safety contracts present, and mental health safety agreement alternatives.
- Evidence-based suicide prevention therapy approaches.
What Is a Safety Contract in Therapy?
A safety contract is a verbal or written agreement between you and your therapist in which you promise not to harm yourself.[1] These contracts are still widely used, but emerging evidence questions whether they actually work.[2][3] Safety contracts are an important topic for anyone who is receiving mental health care or supporting someone in treatment.
History and Purpose of No Harm Contracts in Mental Health
The first no-harm contract mental health application dates to a 1973 study in which a contract for safety was discussed as an assessment tool. The intent of this first discussion was to:[1]
- Explore the collaborative nature of safety.
- Gauge a patient’s risk of harm.
- Share responsibility for safety between the patient and the clinician.
Over the following decades, the notion of a suicide prevention contract began to go well beyond its original context and became more of a legal agreement. Instead of being used solely in long-term outpatient therapy, contracts were also introduced in inpatient units, emergency departments, and even in initial contact with patients, all without evidence to support these uses.[1]
By the 1990s, the majority of mental health professionals used some kind of no-suicide contract. However, their use often wasn’t part of an evidence-based approach to safety, but rather a way of addressing risk management. Today, an estimated 40 percent of clinicians still use no-harm contracts, even though evidence suggests they provide limited protection from liability.[2]
What Research Shows About the Effectiveness of Safety Contracts
Now that you understand where safety contracts came from, the next question is: Do they prevent suicide?
The short answer is no, they don’t. The effectiveness of no-suicide contracts has been studied repeatedly, and the findings consistently fail to show that they reduce self-harm or suicidal behavior. Moreover, growing evidence suggests that they may cause more harm than good.[1][2]
One study found that 65 percent of patients who harmed themselves had previously signed a no-harm contract.[1] This doesn’t mean signing a contract alone caused harm, but it does illustrate that a signature isn’t a substitute for quality, ongoing mental health treatment.
The concern is that contracts can create a false sense of security for clinicians. This, in turn, might reduce the vigilance they need to keep their patients safe. From the patient’s perspective, contracts can feel hollow or even coercive, making it less likely they disclose the full details of their suicidal thoughts.[1][4]
This doesn’t mean that mental health professionals who use contracts are negligent. Rather, many clinicians were trained in an era when contracts like this were standard. The field has now moved on, though, and here is what the evidence actually shows.
Ethical Concerns Safety Contracts Present
A patient in an acute crisis might not be in a position to meaningfully consent to a contract. That being the case, the agreement may not be valid in the first place. This is important to understand because it means you haven’t done anything wrong if you struggled or failed to honor the contract in a crisis.[5]
The ethical concerns safety contracts raise also touch on fundamental questions about consent and the therapeutic relationship itself. As noted earlier, some patients feel like these contracts are coercive to begin with, and introducing that dynamic into the therapeutic relationship can do a lot of harm. When you feel pressured by your therapist to sign something, the interaction can move from a collaboration, where it should be, to an impersonal compliance process.[6]
Mental health risk agreements in therapy should strengthen the therapeutic alliance, not undermine it. But this coercion, even when it’s completely unintentional, can also damage the trust between the patient and therapist. Trust is the foundation upon which effective therapy is built, and loss of trust can have various negative impacts.
Making sure patients are safe usually requires something far more than a contract. It requires an ongoing, collaborative, trust-based process that uses research-informed techniques and clinical judgment.[6][7] Fortunately, there are better options available.
Mental Health Safety Agreement Alternatives
Many therapy crisis intervention tools have been developed in recent years. These approaches share a common thread: They treat you, the patient, as an active participant in the process rather than asking you to promise not to hurt yourself and considering the matter addressed.[8] Below are some of the approaches with the strongest research support.
Collaborative Safety Planning
One of the most effective therapy safety planning methods is collaborative safety planning. It includes six components:[9]
- Personal warning signs.
- Internal coping strategies.
- People and places for distraction.
- Trusted contacts to call for help.
- Professional and crisis resources.
- Reducing lethal means.
The process typically works as follows: A written document is created by you and your clinician. It’s a step-by-step guide to help you navigate a crisis safely. This is a living document that you will revisit and update with your therapist as your life and risk level change.[3]
The primary difference between this approach and a no-harm contract is that, as the patient, you are the author of the plan. You use your own words to describe the warning signs that something is wrong and the coping strategies you can use to manage the crisis.
You can also include people and places that can distract you from the crisis, and contact information for the people you trust to support you. Doing so makes it more likely you will follow the plan in an emergency.[9]
Collaborative safety planning in therapy puts you at the center of your own care, which is why it works where contracts often fail.
These collaborative plans outline professional and crisis resources you can lean on in times of need, connecting you with your therapist and other mental health clinicians when you need them most.
Likewise, you outline ways to reduce the use of lethal means, ensuring greater safety and a lower likelihood of self-harm. The evidence supporting this approach is strong, with a 43-45 percent reduction in suicidal behavior.[4][10]
Other Evidence-Based Suicide Prevention Therapy Approaches
Other evidence-based suicide prevention therapy approaches focus on practical, personalized tools that you can use when you need them.
One strategy is collaborative assessment and management of suicidality (CAMS). This is a structured therapeutic framework where you work with your therapist to determine your level of suicide risk. Then, you work together to identify and address the factors contributing to suicidal thoughts.[11]
A more accessible option is crisis response planning (CRP). The defining component of CRP is that it’s a wallet-sized card you can easily pull out in times of need. That accessibility is intentional: when a difficult moment arrives, having something concrete to reference can make all the difference in how you manage the situation. The CRP card also includes reasons for living, which can make this approach more meaningful and personal to you.[2][8]
Dialectical behavior therapy (DBT) is well-supported as a long-term option. In fact, it’s the best therapy if you experience ongoing suicidal thoughts or have survived more than one attempt. DBT combines individual therapy, skills training, and crisis coaching, so it isn’t just a rapid-response option like CRP. Instead, you go to weekly therapy sessions, have weekly group skills training, and phone coaching when you’re in a crisis.[11]
But no matter which of these approaches is used, one element matters more than anything else: your relationship with your therapist.[7]
What Makes Safety Planning Work
As explained above, what makes safety planning an effective approach is that it’s collaborative. Your voice helps shape the plan, your therapist offers their insights, and trust builds between you. You have a sense of ownership regarding your safety, which makes the plan all the more effective.[12]
Furthermore, when your therapist approaches crisis care with empathy, you will feel safer sharing what you’re experiencing. Honest disclosure like that is what allows for real risk assessment and effective safety planning.[3]
There is also an element of progression that makes safety planning work. With direct, coordinated transitions between levels of care and care providers, there aren’t any gaps where you might feel unsupported or lost. Instead, it’s a smooth process from start to finish, where you’re deeply involved while getting the professional help you need.[3]
Finding Support for Safety in Therapy
If you or someone you know is in therapy or seeking mental health support during a crisis, knowing what good crisis care looks like puts you in a position to ask for it when you need it. The standard of care has evolved, and you’re empowered to ask questions and advocate for an approach that feels right for you. You have the right to request something evidence-based and proven to work.[13] Here’s what that looks like in practice.
What to Look for in a Therapist’s Crisis Approach
When speaking with a therapist, you want someone who discusses warning signs and coping strategies together with you. They should ask what’s helped you in the past and what hasn’t worked. Their treatment of safety planning should be an ongoing conversation with you as well.[3][4]
It’s worth asking your clinician some questions to get a better idea of their approach. Asking, “How do you approach crisis planning?” can be a useful place to start. You might follow that with, “Will we update this plan as things change?” A clinician who is committed to collaborative care with you will welcome these and other types of questions about their process.[3]
Follow-ups matter as well. Evidence shows that outreach after a crisis (even if it’s a short phone call) significantly reduces suicidal behavior. Given that, ask your clinician if they have a follow-up protocol in place and what it looks like.[14]
If, when you meet with a new mental health provider, they present you with a no-harm contract and it isn’t accompanied by any other tools, it’s within your rights to ask whether additional, more personalized approaches are available. If not, it’s okay to keep looking until you find someone whose approach feels right.[1][2]
Mission Connection is here to help you or your loved one take the next steps towards an improved mental well-being.
Find Personalized Therapy With Mission Connection
Reaching out for help, especially when you’re facing a difficult life event, is incredibly courageous. What you get in return should be based on evidence and collaboration, so you have the best chance of navigating your situation most effectively.
We offer that very kind of evidence-based, compassionate care at Mission Connection. You’ll get outpatient treatment that considers the whole person, not just your crisis. You’ll learn how to build a life that feels worth living through collaborative treatment planning and long-term mental health support.
We offer several options for effective care, including in-person programs, virtual telehealth, and a hybrid program that combines in-person and virtual care. If you’ve had care that feels impersonal, or if you feel the weight of shame or stigma associated with suicide, you’re certainly not alone. That’s where better care comes in.
Reach out to us online or call us at 866-833-1822 to learn more about how our approach to crisis prevention uses therapy strategies that are personalized and grounded in the best available research.
If you or someone you know is currently in a mental health crisis, get help immediately by calling 911, the mental health crisis hotline at 988, or the SAMHSA hotline at 1-800-662-HELP.
