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J Am Acad Psychiatry Law 37:3:363-370 (2009)
Copyright © 2009 by the American Academy of Psychiatry and the Law.
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REGULAR ARTICLE

Contracting for Safety With Patients: Clinical Practice and Forensic Implications

Keelin A. Garvey, MD, Joseph V. Penn, MD, Angela L. Campbell, JD, Christianne Esposito-Smythers, PhD and Anthony Spirito, PhD

Dr. Garvey is Fellow in forensic psychiatry, University of California Davis. Dr. Esposito-Smythers is Adjunct Assistant Professor, and Dr. Spirito is Professor, Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI. Dr. Penn is Director, Mental Health Services, Correctional Managed Care, University of Texas Medical Branch (UTMB), Huntsville, TX. Ms. Campbell is Managing Member, Dickey & Campbell Law Firm, PLC, and Adjunct Professor, Drake Law School, Des Moines, IA. Address correspondence to: Keelin A. Garvey, MD, University of California Davis Medical Center, Division of Psychiatry and the Law, 2230 Stockton Blvd, Sacramento, CA 95817. E-mail: keelin_garvey{at}ucdmc.ucdavis.edu

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.






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Copyright © 2009 by the American Academy of Psychiatry and the Law.