Safety contract for self harm

The Suicidal Client: Contracting for Safety

One of my colleagues angrily shared a story about a friend of hers. The friends father had been despondent ever since his wife died a few months ago. He told his daughter that it would be better if he just ended it all and joined his wife.

The daughter was sufficiently alarmed to take him to the local emergency room. There, he was interviewed and asked to sign a Contract for Safety, promising that he wouldnt harm himself. He sighed. He signed. And he was sent home.

His daughter was beside herself: Of course he signed the thing, she told my colleague. He knew if he refused hed be admitted and he didnt want to give up the option. So what was I supposed to do?

Fortunately, this story has a positive ending. The daughter was able to persuade her father to go to a therapist. The therapist was experienced and kind and, possibly because he was about the same age, able to connect with a 70-year-old depressed man who was grieving. But the story is a good illustration of the limitations of the often used Contract for Safety.

Whats Wrong with a Contract for Safety?

Results of Contracts for Safety (CFS), where a client is asked to agree either verbally or in writing that she will not engage in self harm, were first published by Drye, et.al. in 1973 . Although these original authors only investigated its effectiveness with patients in a long term relationship with their therapist, the use of the tool has since become standard practice for many crisis teams and clinicians, even during an initial interview. But are they effective?

A careful review of the literature by Kelly and Knudson at Idaho State Universitys Institute of Rural Health in 2000 showed that no studies demonstrate that contracts are an effective way to prevent suicide .

A 2001 study by B.L. Drew found that of people who attempted suicide in a psychiatric hospital, 65% had signed a CFS . In still another study, this one a 2000 survey of psychiatrists in Minnesota by Dr. Jerome Kroll, 40% had a patient make a serious or successful suicide attempt after signing a CFS.

Contracts for Safety have not been found to be useful with suicidal patients who are psychotic, impulsive, depressed or agitated, who have a personality disorder or who are under the influence of alcohol or street drugs the very patients who are the most likely to show up in emergency rooms.

In fact, there is even some evidence that for people diagnosed with Borderline Personality Disorder, a CFS may make things worse.

There are a number of reasons why clinicians continue to use Contracts for Safety, despite the evidence that when used alone, they may not be helpful and, in some cases, may even be harmful.

First, most clinicians receive limited training in suicidality. The use of the Contract for Safety has become almost folkloric. Confronted with a suicidal client, the clinician may have heard that such a contract is helpful. Doing something, even something that may be ineffective, feels better than doing nothing.

Secondly, some clinicians seem to think that the use and documentation of a CFS protects them from legal liability if the client does commit suicide

Studies have shown, however, that having a CFS does not decrease a clinicians liability. Thirdly, some clinicians think they can relax a bit if they have a contract. They mistakenly believe that having the contract buys them some time to help the client abandon suicide as a solution to his problems.

Finally, a severely mentally ill or intellectually disabled or addicted client may be in no shape to make a contract that represents an informed, responsible decision.

If Not a Contract for Safety, What?

Obtain training: There are other, more effective responses to the threat of suicide than the Contract for Safety. But in order for any of them to be maximally effective, the clinician must develop his or her own expertise. (See related article). Few graduate and professional programs offer adequate training to new clinicians. If you are among those who never received such training, its essential to fill in that gap.

Develop the therapeutic relationship: Limit use of a Contract for Safety to clients with whom you have a long-term solid relationship: In such cases, the contract can be a useful way to open a conversation about their intentions and feelings.

It can be a relief to a long term client that you are taking her despair seriously and that you care enough to explore whether such an agreement would be helpful. When the client is in crisis, consider increasing the frequency of sessions or other types of contact.

Use the contract only as a part of a full risk assessment: A comprehensive risk assessment includes an evaluation of risk factors, an understanding of what has precipitated suicidal thinking, assessment of the individuals plan and access to means, investigation of any history of past attempts and identification of resiliency factors and potential supports.

Assess regularly: Risk assessment is a dynamic process and should be done regularly with clients who present with or have a history of suicidality or self-harm.

Take time to review risk whenever there is a change in presentation, if symptoms persist or get worse, if medications are changed or if the client talks about terminating.

Periodically utilize a tool like the Beck Depression Scale to check for progress with depressed clients. Regularly do a Mental Status Exam. Be sure to assess the client for delusions, hallucinations, a thought disorder or a decrease in capacity for reality testing.

Develop a Safety Plan with your client. A Safety Plan differs from a Contract for Safety in several important ways. Such a plan focuses on what the client will do to keep himself safe rather than what he wont do to harm himself.

Help the client identify her own triggers and situations that put her at greatest risk.
Work with the client to list and practice whatever coping skills he has available.
Determine if the client has access to guns, potentially lethal medications or any other means for hurting herself. Ask/insist that the client give such items to a trusted friend or relative.
Ask the client to permit you to contact family members or other trusted individuals who can be helpful in getting her through a crisis. If possible, involve those individuals in some of the clients sessions to clarify whether they are willing to accept a supportive role and what they can do that is the most helpful for this individual. For example: Do they just need to talk the person through on the phone or do they need to take the person to the hospital?
Identify other sources of support such as the local crisis team, the National Suicide Prevention Lifeline or the local NAMI group. Write down the phone numbers and ask the client to keep them with him.
Collaborate. If a client becomes suicidal, get a release to talk to the prescriber and to collaborate with the local crisis team. With the clients permission, involve the family (see above). Increase your own supervision.

The Contract for Safety has become too much a part of the routine for clinicians when confronted with the suicidal client.

Although it was created as an assessment tool for use with clients who have a relationship with their therapist, it is too often the immediate and only response to suicidality. Clinical decisions regarding risk require a much more thorough and complex assessment of the individual. When there is clinical concern about the clients safety, it is a safety plan, not a contract, that is most likely to result in positive outcomes.

Healthcare form photo available from Shutterstock

Why Therapists Stopped Creating No-Harm Contracts for Safety

It seemed like the simplest thing. A few years ago, a client of mine had been thinking a bit about suicide, but without a specific plan or intent. They would be considered far too low-risk for hospitalization or other crisis services. But I was worried enough that I didn’t want to just send them on their way without doing something. So we wrote out a no-harm contract.

No-harm contracts involve a commitment from the client, often signed, that they will not do anything to harm themselves or anyone else before a specific date. Often that date is the next time the client and therapist will meet, so that the client can be reassessed and the contract revised and re-signed as needed. Some no-harm contracts include specific steps the client would be expected to take before engaging in any harmful behavior.

I gave my client a copy of the contract, and kept the original in the client’s file. I thought I had done the right thing.

When I told my supervisor, I expected a pat on the back.

Instead, I almost lost my job.

The problem with contracting

A no-harm contract isn’t a contract in any legally enforceable sense. If that client actually had hurt themselves, it’s not as though my agency was going to sue the client for breach of contract. There’s no way to meaningfully hold someone to it.

What a no-harm contract does, though, is establish in writing that I believed the client posed some level of risk to themselves. And that, after I recognized that risk and saw a need to intervene, I simply took the client at their word that they would be fine.

This is why no-harm contracts have fallen out of favor over time. There’s no evidence that they work. They may even provide you a false sense of security. They show that you saw a need to intervene to reduce suicide risk, and then that you didn’t actually do much to intervene. Legal scholars have expressed concern that this could open therapists up to legal liability if a client dies by suicide* and the family files a complaint or lawsuit.

What to do instead

If you have a client who you believe poses a risk to themselves or to others, but that risk is not significant enough to warrant more intrusive forms of intervention, then it is generally considered best to develop a specific safety plan. That plan involves a sequence of specific actions the client can take, ranging from minimal tasks like journaling or calling a particular friend to crisis options like going to an emergency room or calling the National Suicide Prevention Lifeline (988). It ensures that the client knows exactly what to do if they feel their mental state deteriorating, even if you aren’t immediately available.

A safety plan may be one component of a more comprehensive safety strategy. That strategy may also include steps like increasing the frequency of contact, involving other health care professionals, increasing social support, and removing access to lethal means.

That’s not the only change

Suicide prevention, assessment, and intervention has actually changed in a number of meaningful ways in the past few years. For example, new research is telling us that screening instruments aren’t all that useful, and that many clients will not talk about their suicidal thoughts even when asked directly. These findings shape how we work with clients who may be contemplating suicide.

In response to rising suicide rates, a number of states implemented additional suicide training requirements for therapists.

To learn more about safety planning, current research, and much more, you can take our 6-hour continuing education course on Suicide Prevention, Assessment, and Intervention at SimplePractice Learning.

And for what it’s worth: The next time my client came in, we created a more thorough safety plan. I kept my job, and, more importantly, the client stayed safe.

Complete SimplePractice Learning course information, including applicable CE approvals and refund, grievance, and accommodations policies, is available via the course link provided above.

Credit insurance - detailed instructions on insurance

Updated: 10/26/2022

Often, banks, along with a loan, offer the client to take out insurance. Considering all the nuances in the contract, this financial instrument can help the borrower cope with the financial burden under difficult life circumstances.

What you need to know about life and health insurance?

A bank can offer such a policy to a client along with any loan. It provides the lender a guarantee that the debt will be repaid, even if something happens to the borrower. For example, he will not be able to work due to a disability or an accident.

Such policies also come with a deductible, when only a certain period of illness is paid. They are are cheaper, but the client needs to be ready to pay part of the sum insured to the bank on his own.

However, there are many nuances with this type of insurance. For example, some insurers do not pay compensation if a person is injured during an extreme sport sports. Or the client may be denied insurance altogether if he is relatively recent has undergone a complex operation or has a serious illness at the moment.

DOM.RF Bank also insures life and health risks. For example, the onset of death from any cause, including an accident. As well as health insurance at risk obtaining a disability of the first group. When applying for a mortgage loan, the risk is most often insured receiving the first and second groups of disability. However, it should be noted that insurance distributed to the second group is often more expensive, since in this category disabilities are the most common fraudulent schemes.

In addition, there is an additional range of insurances that various banks can offer − from job loss or temporary disability. These insurances can be useful to clients, however, they are more expensive, so the borrower needs to objectively assess the likelihood of data risks and their financial capabilities. The most suitable option for this insurance will be for people who work in hazardous production, or for employees of firms experiencing difficulties, with a high probability of downsizing.

What do you need to know about collateral insurance (property insurance)?

For example, an apartment purchased using a mortgage loan. Thus it is possible protect yourself from financial losses if something serious happens to mortgage housing (fire, explosion or flood). The subject of pledge is insured against all risks associated with violation of constructive elements apartments or complete loss of real estate. Also, the insurance policy can include additional points. For example, to insure the interior decoration of the apartment if your pipe suddenly bursts. More about it can be found in the article - "How and why insure mortgage."

When concluding a property insurance contract, you should pay attention to the fact that the beneficiary in the event of an insured event is usually the bank.

Are suicide and intentional self-mutilation insured events?

If the suicide occurred within two years after the conclusion of the insurance contract, then it is not an insured event. However, if a person commits suicide after 2 years after the insurance is issued, then this incident is recognized as an insured event.

It is also worth noting the practice of deliberate self-harm to a mortgage borrower who has taken out insurance. In this case, even if the medical commission records the harm done, then this the accident will not be considered an insured event.

Here is an excerpt from the Civil Code of the Russian Federation Article 963. Consequences of the occurrence of an insured event through the fault of the policyholder, beneficiary or insured person

The insurer is not exempt from paying the sum insured, which, under the personal agreement insurance is payable in the event of the death of the insured person, if his death has occurred due to suicide, and by that time the insurance contract had been in effect for at least two years.

Is it possible to cancel the insurance after registration?

Yes, in accordance with the law, this can be done. As a rule, insurance companies companies have a special period (14 days) during which the client can change your mind and cancel insurance. To do this, he needs to contact by phone to the insurance company or come to the office. If there were no signs during the specified period insured event, the insurer will pay the client the required amount.

Can I get back the cost of insurance if I repay the loan ahead of schedule?

It depends on the conditions specified in the policy, as well as the date of registration of the insurance contracts. Since September 2020, a new law has come into force, according to which you can return part of the money for insurance in case of early repayment of the loan in proportion to the remaining period. At in this regard, it only applies to contracts concluded from September 1, 2020. If the contract concluded earlier, the old order will apply.

In case of early repayment, the following procedure should be followed:

You need to take a certificate of full closing of the loan in the office or in your personal account mobile application of the Bank

Apply with it to the insurance / bank with an application for a refund

Wait for a response from the insurance/bank

It is worth noting that if the insured event has already occurred and a payment has been made, return the cost insurance in case of early repayment will not work, even if until the end of the policy there are some years.

How to act in case of an insured event?

We hope you will never need this information, but just in case, we will describe the order actions:

Contact the bank or insurance company with which you have concluded an agreement

Fill out an application for payment

Provide an insurance contract or policy, as well as identification documents

Present all the necessary documents confirming the fact of the occurrence of the insured event. exact list documents provided by the insurance company

It should be noted that during the procedure, the insurer may request any clarifying information, as well as documents to confirm it. The main thing is to remain calm and act according to instructions. This will allow you to quickly prepare the necessary documents and receive an insurance payment.

Can a bank add the cost of insurance to a loan?

Banks have the right to include the price of the policy in the loan agreement and even charge interest on it, but only with the consent of the client. Otherwise, you can contact the bank for recalculation of the loan amount, but you will have to pay for insurance separately.

Why is it often unprofitable to refuse insurance?

When you take out insurance, you can get a reduced credit rate.

In the event of an insured event, you will have to bear all financial costs yourself

When canceling insurance, the borrower takes on additional risks

It is worth remembering that not only property is inherited, but also debts. If the client had insurance at the time of death, then the debt to the bank will be repaid by the insurance company. Otherwise, in order not to inherit the debt, the heirs will have to refuse and from property

In case of unforeseen circumstances, the borrower will still have to accumulate a financial cushion, volumes of which can significantly exceed the cost of insurance.

How to get a loan profitably and not miscalculate?

The conclusion of an insurance contract, except for the mandatory one when applying for a mortgage, remains at the discretion borrower. In each specific case, you can compare what will be more profitable in order to make a decision. For example, refuse insurance and pay increased interest or buy an insurance policy.

The purchase of an insurance product gives the client a guarantee that, with the help of compensation from the insurance company, he or his heirs will be able to repay the debt to the bank if trouble happens. Moreover, since banks are primarily interested in repaying the debt, they will act in concert with the client.

The main thing is to use the services of reliable credit organizations that value their reputation and work only with trusted insurance companies. After all, the bank does not profit with the help of insurance on the client, but insures itself and protects the client in order to give the borrower a lower bet.

And in any case, you need to carefully study the documents and the proposed conditions in order to compare and choose the best solution for you.

The Russian Foreign Ministry has published draft agreements with NATO and the United States on security

The Russian Ministry of Foreign Affairs has published draft agreements with the United States and an agreement with the NATO military alliance on guarantees and security.

“During the meeting at the Russian Foreign Ministry on December 15 p. The American side received draft treaties between the Russian Federation and the United States of America on security guarantees and agreements on measures to ensure the security of the Russian Federation and the member states of the North Atlantic Treaty Organization... We expect that, on the basis of our draft treaties and agreements, the United States will in the very near future time will enter into serious negotiations with Russia on a critically important issue for maintaining peace and stability, ”the press service of the Russian department reports.

In particular, the draft agreement between the Russian Federation and the United States on security guarantees implies the following agreements:

- not to take actions that affect the security of the other side; not to take actions that would undermine the fundamental security interests of the other party;

- not to use the territory of other states for the purpose of preparing or carrying out an armed attack against the other side;

- The United States undertakes to exclude further expansion of NATO to the east and refuses to admit countries that were previously part of the USSR into the alliance; The United States will also not create military bases on the territory of countries that were part of the USSR and are not members of NATO;

- Refuse to deploy weapons and forces in those areas where it will be perceived by the other side as a threat to national security;

- to refrain from carrying out flights of heavy bombers in nuclear and non-nuclear equipment outside the national airspace, as well as from the presence of surface warships of all classes outside national territorial waters, from where they can hit targets on the territory of the other side;

- not to deploy short-range intermediate and short-range missiles outside its territory, as well as to return weapons of this type already deployed outside the territory; Moscow and Washington will eliminate all existing infrastructure for the deployment of nuclear weapons outside the national territory;

- exclude the deployment of nuclear weapons outside their territory.

It is noted that the agreement may enter into force from the date of receipt of the last written notification of the fulfillment by Russia and the United States of the necessary domestic procedures for this.

The second document, an agreement on measures to ensure the security of the Russian Federation and NATO member states, among other things, implies:

- an obligation not to create conditions or situations that could pose or be regarded as a threat to national security;

- organization of "hot" telephone lines for emergency contacts and the use of all available mechanisms and instruments of confidence building measures;

- confirmation that the parties to the agreement do not consider each other opponents;

- the refusal of the Russian Federation and all members of the alliance, as of May 27, 1997, to deploy their armed forces and weapons on the territory of all other European states in addition to the forces deployed on this territory at that time;

- Refusal to deploy ground-based intermediate and shorter-range missiles in areas from which they are capable of hitting targets on the territory of the other side;

- NATO's commitment to exclude further expansion of the bloc, as well as to abandon military activities on the territory of Ukraine and other countries of Eastern Europe, Transcaucasia and Central Asia.

The parties to the agreement may withdraw from it, the contract in this case is terminated 30 days after the depositary receives the said notification, follows from the draft document. It may enter into force from the date of its transfer.

On December 1, Russian President Vladimir Putin called for the start of negotiations on the non-expansion of NATO to the east. The President said that Russia, in dialogue with Western countries, would strive to reach agreements on NATO's refusal to expand to the east and deploy weapons near the country's borders.

On December 8, Vladimir Putin said that during his talks with US President Joe Biden, issues of regional issues, the conflict in the southeast of Ukraine, and the expansion of the NATO bloc to the east, including at the expense of Ukraine, were touched upon. According to him, Moscow proceeds from the fact that while ensuring security, it should be global and apply equally to everyone.

In 2017, Putin recalled that NATO's promise to the Soviet Union not to push its borders east of Germany was not put on paper.

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