title: Contracting for safety with patients: clinical practice and forensic implications.
abstract: The contract for safety is a procedure used in the management of suicidal patients and has significant patient care, risk management, and medicolegal implications. We conducted a literature review to assess empirical support for this procedure and reviewed legal cases in which this practice was employed, to examine its effect on outcome. Studies obtained from a PubMed search were reviewed and consisted mainly of opinion-based surveys of clinicians and patients and retrospective reviews. Overall, empirically based evidence to support the use of the contract for safety in any population is very limited, particularly in adolescent populations. A legal review revealed that contracting for safety is never enough to protect against legal liability and may lead to adverse consequences for the clinician and the patient. Contracts should be considered for use only in patients who are deemed capable of giving informed consent and, even in these circumstances, should be used with caution. A contract should never replace a thorough assessment of a patient's suicide risk factors. Further empirical research is needed to determine whether contracting for safety merits consideration as a future component of the suicide risk assessment.
authors.affiliation: University of California Davis Medical Center, Division of Psychiatry and the Law, 2230 Stockton Blvd, Sacramento, CA 95817, USA. keelin_garvey@ucdmc.ucdavis.edu
authors.forename: Keelin A
authors.initials: KA
authors.lastname: Garvey
authors.forename: Joseph V
authors.initials: JV
authors.lastname: Penn
authors.forename: Angela L
authors.initials: AL
authors.lastname: Campbell
authors.forename: Christianne
authors.initials: C
authors.lastname: Esposito-Smythers
authors.forename: Anthony
authors.initials: A
authors.lastname: Spirito
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D032982:Contracts / Q000331:legislation & jurisprudence*; D005104:Expert Testimony / Q000331:legislation & jurisprudence; D006801:Humans; D007258:Informed Consent / Q000331:legislation & jurisprudence; D016365:Liability, Legal; D008318:Malpractice / Q000331:legislation & jurisprudence; D016743:Mental Competency / Q000331:legislation & jurisprudence; D010817:Physician-Patient Relations; D018570:Risk Assessment / Q000331:legislation & jurisprudence; D012308:Risk Management; D012449:Safety / Q000331:legislation & jurisprudence*; D013405:Suicide / Q000331:legislation & jurisprudence*; D000092864:Suicide Prevention