Safety Planning: An Essential Feature of Cognitive Behavior Therapy for Suicide Prevention

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What is a safety plan, and how can clinicians use it to help patients with suicidal behavior?

A safety plan is a critical evidence-based intervention that can reduce suicidal behavior, either as a standalone intervention or as part of a comprehensive treatment plan.1 The safety planning intervention described in this article was developed by Barbara Stanley, PhD, and Gregory K. Brown, PhD, and has been found to be effective at reducing suicidal behavior.2,3 Since its development, this critical evidence-based intervention has been embraced by clinicians around the world and extensively employed in a wide range of behavioral health settings. It is also commonly taught as part of suicide prevention curriculum.

The purpose of the safety plan is to provide patients who are at heightened risk for suicide with concrete, actionable coping strategies they can use during a suicidal crisis to decrease their risk of attempting suicide. In addition to its practical and intended use, a safety plan also conveys hope by demonstrating to an individual with suicidal ideation that there are more effective ways of managing their problems.

A safety plan is different from a no-suicide contract. Research has shown that no-suicide contracts are ineffective and can lead patients to withhold information about suicidal thoughts and behaviors from their providers.4

At the beginning of treatment, or if a previously non-suicidal patient begins reporting suicidal risk factors, it is important to determine risk for suicide by conducting a comprehensive suicide risk assessment. This may include patients who have experienced previous episodes of suicidal ideation or behavior because, when the previous suicide risk is greater than the current risk, it is a better predictor of suicidal behavior.5 Safety planning should then be conducted immediately upon determining that a patient is at heightened risk for suicide.

As with all interventions, clinicians should provide patients with a rationale for safety planning. If possible, clinicians can emphasize the collaborative nature of the intervention by sitting next to the patient when completing the plan. Clinicians should start by eliciting warning signs that risk for suicide is increasing. This helps patients gain awareness of when they need to access and use their safety plan. It is typically easier for patients to implement safety plan coping strategies at the early stages of a suicidal crisis than it is after the episode escalates in intensity. Noticing warning signs can help patients begin using coping strategies so that a more severe crisis and related suicidal behavior are prevented.

Once the clinician and patient have a good understanding of the patient’s warning signs, the first section of the safety plan can be completed. Warning signs may include feelings of hopelessness or irritability; thoughts like, “I’ll always be alone”; behaviors like arguing with a parent; and/or physiological sensations such as intense pain from a chronic medical condition. They can also include events, such as the anniversary of the death of a loved one.

The next part of the safety plan involves identifying different categories of coping strategies patients will use once they have recognized that they are at heightened risk for suicide. The safety plan begins with internal coping strategies the patient can use without assistance from others and progresses through incrementally more intensive strategies the patient can use if the initial strategies are ineffective.

Internal coping strategies typically involve experiences that distract the patient from their suicidal thoughts, emotional distress, or urges by diverting their attention onto other activities, stimuli, or sensations. Clinicians can identify internal coping strategies by asking patients, “What have you done in the past that has been at least a little helpful when you have experienced any of these warning signs?” If the patient has trouble identifying coping strategies, you can make suggestions.

Some patients may benefit from focusing on sensory experiences like listening to music or taking a hot shower. Patients may also engage in a distracting activity, such as going for a walk, watching an entertaining TV show, or playing video games. When completing this section of the safety plan, clinicians should be as specific and detailed as possible. For example, if a patient identifies listening to music as a coping strategy, the clinician should find out exactly which songs or artists the patient finds helpful and how the patient will listen to them (eg, on their phone).

After completing each coping strategy section, clinicians elicit feedback from patients. Clinicians should assess how likely it is that the patient will use the strategies in a suicidal crisis and problem solve for any obstacles that may get in the way. A simple way to assess the utility of each part of the plan is to ask, “Thinking about how you feel when in a suicidal crisis, how likely are you to use these strategies on a scale of 0 to 100, where 0 indicates that you will definitely not use these strategies and 100 indicates that you have no doubt that you will use them?” If the patient provides a rating of less than 90, the clinician will need to do some additional work to assess practical problems or beliefs that may be interfering with the patient’s likelihood of using the strategies. This might involve eliminating some strategies and replacing them with other, more helpful ones.

For the next section of the safety plan, patients are asked to identify individuals and social settings that can serve as a distraction during a suicidal crisis. It should be emphasized that these are not individuals the patient is contacting to directly ask for help, but rather individuals who can provide social experiences that can divert the patient’s attention from suicidal thoughts or urges. The identified individuals should be known to be responsive and accessible, and the patient should be explicit about the medium for communication (ie, via phone, via text, or in person).

Patients may also wish to identify social locations they can visit, such as a local park, a coffee shop, or an AA meeting. Many patients find it helpful to be around other people during a suicidal crisis, even if the people are strangers. As with the section on internal coping strategies, clinicians should assess the likelihood that patients will use the strategies in this section before moving on.

Next, the patient will identify individuals that they can contact to directly ask for support. The identified individuals should have a history of being responsive or helpful when the patient has asked them for support in the past. The patient will need to determine whether they feel comfortable explicitly stating that they are having a suicidal crisis, or whether they would prefer to be vague (ie, telling the person they feel “down” or “anxious” instead). If the patient is not sure whether an identified person will be willing and able to help, they can have a conversation with the person in the coming week about their desire to reach out for support if needed. They may even tell the person what they would like them to do if they call on them for support. If the patient is not comfortable having this type of conversation, it may be helpful for the clinician to provide some brief coaching on communication skills and to offer to roleplay the conversation.

Once support people have been identified, clinicians should be explicit about the order in which the patient will contact them and the medium for contact. Finally, the names and phone numbers of the individuals should be added to the safety plan.

If the patient has moved through all the previous coping strategies and is still in suicidal crisis, the final strategy is to contact mental health providers or facilities that can intervene with professional help. Typically, the clinician’s name will be at the top of this section, followed by additional mental health clinicians and trusted medical professionals. Clinicians should be explicit with clients about how emergencies are handled both during and after business hours, whether they have an answering service, or if there is another provider in the practice who may be on call if the patient experiences a crisis after hours.

This section can also include hotline services, like the new mental health crisis number, 988, which is now available in the United States. Finally, patients should designate a local urgent care service or psychiatric emergency room if hospitalization is required. Patients should also determine how they will get to their designated facility (ie, will they call an ambulance or ask a friend or family member to drive them?).

The next step in safety planning is making the patient’s environment safer. Clinicians should focus on reducing the patient’s access to their identified means for suicide. It is important to restrict access to firearms, regardless of whether the patient expresses a desire to use a firearm for suicide. In the United States, approximately half of individuals who commit suicide do so using firearms.6 Having a firearm in the household is also associated with a 5-fold increase in death by suicide.7

When asking the patient about their chosen means for suicide, collaboration is key. Often, patients view having access to a means for suicide as a coping strategy in and of itself. A patient may consider a stockpile of pills hidden in a drawer an “escape hatch” they can use if their problems become overwhelming. That patient may then have a negative reaction to the clinician’s suggestion that they turn their medication over to a friend for safekeeping.

Clinicians can be collaborative by asking patients for suggestions to make their environment safer before offering their own suggestions. For instance, a patient may prefer keeping a pill box with 1 week’s worth of medication while a family member has possession of the remaining bottle. A patient who is unwilling to give up their firearm may be willing to store it in a locked safe and give the key to a trusted friend. Clinicians can emphasize that the measures are temporary and will last only until the suicidal crisis is over.

The last component of the safety plan is identifying reasons for living. Clinicians should work with patients to identify at least 1 thing that makes the patient’s life worth living. The simplest way to help patients identify reasons for living is simply to ask, “What is 1 thing that is most important and worth living for?” If patients have difficulty identifying 1 reason for living, clinicians can prompt them by asking about different areas where individuals often find meaning, including relationships, important goals, or religion and spirituality. If the patient is still having trouble identifying a compelling reason for living, the clinician might suggest that even the potential of having a future reason for living, or the possibility that life might seem worthwhile, can also be reasons for living. For example, a young female patient of mine did not have children, but she identified wanting to be a mother sometime in the future as a potential reason for living.

Once the safety plan is complete, the clinician’s work is to increase the likelihood that the patient will actually use it in a suicidal crisis. The clinician will start by asking for general feedback about the safety planning process and whether the patient believes the plan will be helpful. The clinician will then try to uncover obstacles that might get in the way of the patient using the plan when needed.

Sometimes practical problems may get in the way. For example, the patient may not remember to use their plan, particularly when they are in the midst of a suicidal crisis. It is usually a good idea to ask patients to review their safety plan every day, regardless of whether they are feeling suicidal. Clinicians should be explicit with patients about when they will review their plan. Most patients can benefit from reviewing their plan each morning, as this helps keep the plan at the forefront of their minds throughout the remainder of the day. Another obstacle might be the accessibility of the plan. The clinician will want to be sure the patient has access to their plan wherever they are. Patients may wish to take a picture of it with their phone, or to make multiple copies and store them in different locations (ie, in their car, in their desk at work, on a nightstand).

Some patients may express doubt that the plan will be helpful. The clinician can communicate that the safety plan is not meant to solve all their problems—the safety plan is just meant to keep the patient alive so that they can continue to work on more longstanding problems in therapy. The clinician can also stress that the safety plan can evolve and change over time, as the patient determines that some of the strategies are not helpful and learns new strategies in therapy that may be more helpful. The patient just needs to agree to use the plan, regardless of whether they are confident it will be helpful.

Each subsequent session with the patient should begin with a review of the plan and a discussion of any strategies the patient has tried to determine their utility. If a patient outright refuses to use their safety plan, clinicians should consider whether the patient should be referred to a higher level of care.

Dr Hindman is a licensed clinical psychologist at the Beck Institute for Cognitive Behavior Therapy in Bala Cynwyd, Pennsylvania. Ms Fleming is the communications manager at the Beck Institute for Cognitive Behavior Therapy.

References

1. Nuij C, van Ballegooijen W, de Beurs D, et al. Safety planning-type interventions for suicide prevention: meta-analysisBr J Psychiatry. 2021;219(2):419-426.

2. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256-264.

3. Ferguson M, Rhodes K, Loughhead M, et al. The effectiveness of the safety planning intervention for adults experiencing suicide-related distress: a systematic reviewArch Suicide Res. 2022;26(3):1022-1045.

4. Rudd MD, Mandrusiak M, Joiner TE Jr. The case against no-suicide contracts: the commitment to treatment statement as a practice alternativeJ Clin Psychol. 2006;62(2):243-251.

5. Beck AT, Brown GK, Steer RA, et al. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatientsSuicide Life Threat Behav. 1999;29(1):1-9.

6. Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based studyAnn Intern Med. 2019;171(12):885-895.

7. Simon RI. Gun safety management with patients at risk for suicide. Suicide Life Threat Behav. 2007;37(5):518-526.