Suicide in AmericaPage 10 of 14

8. Safety Plans

Safety planning is a provider-patient collaborative process—a prevention tool designed to help an individual manage suicidal thoughts. The safety planning process produces a written plan that restricts access to means for completing suicide, encourages problem-solving and coping strategies, enhances social supports, and identifies a network of emergency contacts. Safety plans should be tailored to the individual, identifying specific warning signs as well as coping strategies that have been effective in the past.

Developing the Plan

Although no universally accepted safety planning method exists, the safety planning intervention has gained widespread acceptance in the suicide prevention community and has been incorporated into numerous treatment guidelines and interventions. The plan is collaboratively built by the clinician and patient and encourages individuals to engage in six sequential steps when feeling suicidal:

  1. Identify early warning signs
  2. Employ internal coping strategies
  3. Distract with social engagement or change of environment
  4. Access suicide-protective social support
  5. Seek help through crisis resources
  6. Restrict access to lethal means (Boudreaux et al., 2017)

The Safety Planning Intervention has a strong empirical foundation supporting each of its six steps, as well as evidence that it improves the average number of outpatient mental health visits for suicidal patients during the 6 months following the index ED visit, when compared with treatment as usual (Boudreaux et al., 2017).

The plan and the process of developing it should be included in the medical record, and the patient should receive a copy. The safety plan should be specific and should list situations, stressors, thoughts, feelings, behaviors, and symptoms that suggest periods of increased risk, as well as a step-by-step description of coping strategies and help seeking behaviors.

Monitoring the Plan

A common misconception is that suicide risk is an acute problem that, once dealt with, ends. Unfortunately, individuals who are suicidal commonly experience a return of suicide risk following setbacks, including relapse to substance use, a distressing life event, increased depression, or any number of other situations. Sometimes suicidal behavior even occurs in the context of substantial improvement in mood and energy. Therefore, monitoring for signs of a return of suicidal thoughts or behavior is essential (CSAT, 2015).

Monitoring emphasizes the importance of watching for a return of suicidal thoughts and behaviors, following up with referrals, and coordinating with providers who are addressing the patient’s suicidal thoughts and behaviors. There is a tendency to refer a patient to another provider and assume that the issue has been taken care of. This is a mistake. It is essential that you follow up to determine that the person kept the appointment. It is also critical to coordinate ongoing care and to alert other providers when a patient has relapsed and may be vulnerable to suicidal thoughts (CSAT, 2015).

Monitoring can include following up with the ED when a patient has been referred for acute assessment as well as continual coordinating with mental health providers, case managers, or other professionals. The client’s condition and your responses should be documented, including referrals and the outcomes of the referrals. Monitoring actions include:

  • Confirming that the client still has a safety plan in effect.
  • Monitoring and updating the treatment plan.
  • Confirming that a client has kept referral appointments.
  • Following up if a recurrence of suicidal thoughts or attempts is observed.
  • Keeping family members engaged in the treatment process.
  • Confirming that the client and the family have an emergency phone number to call.
  • Confirming that the client does not have access to a method of suicide.
  • Completing a formal treatment termination summary when this stage of care is reached. (CSAT, 2015)

These approaches typically include followup contact and use diverse modalities (home visits, mail, telephone, e-mail) to engage recent suicide attempt survivors in continued treatment to prevent re-attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and personal therapy and group therapy. Approaches that engage and connect people to peers and providers are especially important because many attempters do not present to aftercare; 12% to 25% re-attempt within a year, and 3% to 9% of attempt survivors die by suicide within 1 to 5 years of their initial attempt (Stone et al., 2017).