Safety planning is a provider-patient collaborative process—a prevention tool designed to help an individual manage suicidal thoughts. Safety planning produces a written plan that restricts access to means for completing suicide, encourages problem-solving and coping strategies, enhances social support, 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 (DVA/DOD, 2019).
Developing the Plan
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 a clinician and a patient and encourages individuals to engage in six sequential steps when feeling suicidal:
- Identify early warning signs
- Employ internal coping strategies
- Distract with social engagement or change of environment
- Access suicide-protective social support
- Seek help through crisis resources
- Restrict access to lethal means (Harmer et al., 2022)
Safety Planning Intervention has a strong empirical foundation supporting each of its six steps. It also 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 a safety plan 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 (DVA/DOD, 2019).
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 any number of 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, 2017).
There is a tendency to refer a patient experiencing suicidal thoughts and behaviors to another provider and then assume that the issue has been taken care of. This is a mistake. It is essential to follow up with the provider 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. Monitoring emphasizes the importance of watching for a return of suicidal thoughts and behaviors, following up with referrals, and continually coordinating with providers who are addressing the patient’s suicidal thoughts and behaviors (CSAT, 2017).
Monitoring can include following up with the ED when a patient has been referred for acute assessment as well as 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.
It is important to determine if the client still has a safety plan in place that is monitored and updated, especially if a recurrence of suicidal thoughts or attempts is observed. Additional followup should include:
- 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, 2017)
Followup contact can include home visits and mail, telephone, e-mail contact to engage recent survivors in continued treatment. 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).
The Diagnostic and Statistical Manual, Fifth Edition has been revised to include new ICD-10-CM codes to flag and monitor suicidal behavior and nonsuicidal self-injury. The codes can be used without the requirement of another diagnosis. Because suicidal behavior may be helpful to track or flag for clinical attention and care of individuals, ICD-10-CM codes are now available for use by any clinician and do not require a mental disorder diagnosis. The suicidal behavior ICD-10-CM codes can be used for individuals who have engaged in potentially self-injurious behavior with at least some intent to die because of the act. Evidence of intent to end their life can be explicit or inferred from the behavior or circumstances. A suicide attempt may or may not result in self-injury (Psychiatry Online, 2022).