contracts are not, however, a guarantee of safety.
Clients make contracts with input from nurses or
other health care professionals. Contracts also can
specify when clients will be re-evaluated. The litera-
ture is divided on the effectiveness of such contracts
or agreements (Potter & Dawson, 2001; Miller, Jacobs
& Gutheil, 1998). At no time should a nurse assume
that a client is safe just because a contract is in place.CREATING A SUPPORT SYSTEM LIST
Suicidal clients often lack social support systems such
as relatives, friends, or religious, occupational, and
community support groups. This lack may result from
social withdrawal, behavior associated with a psy-
chiatric or medical disorder, or movement of the per-
son to a new area because of school, work, change in
family structure or financial status. The nurse as-
sesses support systems and the type of help each per-
son or group can give a client. Mental health clinics,
hotlines, psychiatric emergency evaluation services,
student health services, church groups, and self-help
groups are part of the community support system.
The nurse makes a list of specific names and agen-
cies that clients can call for support; he or she obtains
client consent to avoid breach of confidentiality. Many
suicidal people do not have to be admitted to a hos-
pital and can be treated successfully in the community
with the help of these support people and agencies.Family Response
Suicide is the ultimate rejection of family and friends.
Implicit in the act of suicide is the message to others
that their help was incompetent, irrelevant, or un-
welcome. Some suicides are done to place blame on a
certain person—even to the point of planning how
that person will be the one to discover the body. Most
suicides are efforts to escape untenable situations.
Even if a person believes love for family members
prompted his or her suicide—as in the case of some-
one who commits suicide to avoid lengthy legal bat-
tles or to save the family the financial and emotional
cost of a lingering death—relatives still grieve and
may feel guilt, shame, and anger.
Significant others may feel guilty for not know-
ing how desperate the suicidal person was, angry
because the person did not seek their help or trust
them, ashamed that their loved one ended his or her
life with a socially unacceptable act, and sad about
being rejected. Suicide is newsworthy, and there may
be whispered gossip and even news coverage. Life in-
surance companies may not pay survivors’ benefits to
families of those who kill themselves. Also the one
death may spark “copycat suicides” among family
members or others, who may feel they have been15 MOODDISORDERS ANDSUICIDE 365
No-suicide contractcommit suicide such as sharp objects, shoelaces, belts,
lighters, matches, pencils, pens, and even clothing
with drawstrings.
Institutional policies for suicide precautions again
vary, but usually staff members observe clients every
10 minutes if lethality is low. For clients with high
potential lethality, one-to-one supervision by a staff
person is initiated. This means that clients are in di-
rect sight of and no more than 2 to 3 feet away from
a staff member for all activities including going to the
bathroom. Clients are under constant staff observa-
tion with no exceptions. This may be frustrating or
upsetting to clients, so staff members may need to ex-
plain the purpose of such supervision usually more
than once.
INITIATING A NO-SUICIDE CONTRACT
The nurse can implement a no-suicide contract at
home as well as in the inpatient treatment setting.
In such contracts, clients agree to keep themselves
safe and to notify staff at the first impulse to harm
themselves (at home, clients agree to notify their care-
givers; the contract must identify backup people in
case caregivers are unavailable). The urge to commit
suicide may return suddenly, so someone must always
be available for support. A list of support people who
agree to be readily available should be generated.
Most suicidal people adhere to no-suicide con-
tracts because they appeal to the will to live. These