After the clinician and patient have developed plans for steps 1 through 5 and reviewed access to lethal means, the clinician should review the entire plan with the patient in order to assess the patient’s feelings about it and his or her willingness to use it. The clinician can explore any hesitancy about using the plan and engage in techniques (e.g., role play, problem solving) to help increase the patient’s willingness. Once the patient has agreed to use the plan, he or she should be given a copy of it and there should be a discussion of where the plan will be kept and how the patient will have easy access to it. For instance, the patient may wish to take a picture of the plan on his or her phone, make multiple copies of the plan and put them in places where they are accessible, or make a small copy of the plan that could fit in a wallet or billfold. Further, the clinician should also keep a copy of the plan for his or her records. A template for the safety plan is available at suicidepreventionlifeline.org, listed in the resource section of this course. It is worth noting that the once popular “no-suicide contracts” (patients’ written commitment to maintain their safety and to not make a suicide attempt) are no longer considered an appropriate intervention for suicidal patients. Not only is there is no empirical evidence supporting their use, but studies that have investigated
no suicide contracts have found them less effective than other safety planning interventions (Bryan, Mintz, Clemans, Leeson, et a., 2017). Crisis Cards Crisis cards are another form of intervention available to clinicians when patients are determined to be at a moderate level of risk or lower. They must, however, provide more than just emergency numbers. Like safety planning intervention, crisis cards highlight mood regulation techniques, pleasant activities, and emergency numbers in the event that other techniques fail to reduce suicidal symptoms. Using this technique, clinicians assist patients to match protective behaviors with feelings, thoughts, or nonprotective behaviors that might activate a suicidal crisis. For example, agitation may be met with relaxation and/or exercise. Loneliness may be addressed with behavioral activation with an interpersonal focus, such as calling a friend. Each suicidal crisis trigger is then written on a card with an identified protective symptom-matching technique to be used when the trigger occurs. Thorough assessment aids in the creation of symptom-matching hierarchies (Joiner et al., 2009). Patients can keep these cards handy to consult as needed. Box 3 outlines the steps for creating a crisis card.
BOX 3: STEPS FOR CREATING A CRISIS CARD 1. Explain the rationale to the patient: I’d like us to come up with some steps you can take if you become upset or start thinking about suicide. It can be hard to think clearly when you are having this kind of crisis, so I’d like us to write the steps on this index card (or keep them as a note in your smart phone), and you can pull out these steps when you realize you are thinking about suicide. 2. Brainstorm with the patient things that make him or her feel better. Clinicians can ask: What have you found helps you when you feel badly? How have you taken the edge off intense feelings? How do you distract yourself from suicidal thoughts? What helps you feel even a little better? Helpful activities are ones that have worked in the past or require at least one of the following: ○ Attention (e.g., working on a puzzle requires attention; watching television does not require attention). ○ Physical activity. ○ Increased belongingness (e.g., calling a friend, going to a place with people, such as a restaurant or mall). 3. List the helpful activities on the card in a step format. Example : When I’m upset and thinking about suicide, I’ll take the following steps: ○ Step 1 : [pleasurable activity or therapy skill]. ○ Step 2 : [pleasurable activity or therapy skill]. ○ Step 3 : [pleasurable activity or therapy skill]. ○ Step 4 : Repeat all of the above. ○ Step 5 : If the thoughts continue, get specific, and I find myself preparing to do something, I’ll call (insert number of emergency call person) or 1-800-273-TALK. ○ Step 6 : If I still feel suicidal and don’t feel like I can control my behavior, I’ll call 911 or go to the emergency department. National Suicide Prevention Lifeline as a resource for outpatient care
call and text centers reduce suicidal crises for both adults and adolescents (Busby, King, Brent, Grupp-Phelan, Gould, et al., 2020; Goodman, 2020; Labouliere, Stanley, Lake, & Gould, 2020). Clinicians are now including the lifeline in their treatment and safety plans (Stanley et al., 2018) and the numerous health organizations advocate for utilization of the lifeline following discharge from emergency departments and other settings when a bridge in clinical care may be needed from time to time (Graves, Mackelprang, Van Natta, & Holliday, 2018).
Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Suicide Prevention Lifeline (NSPL) serves as a triage service for a number of crisis call centers throughout the United States that have received specialized training offered by the American Association of Suicidology (AAS). By dialing 1-800-273-TALK, callers are routed to the nearest of the more than 160 certified call centers. Compelling research findings suggest that national
ADULT CLINICAL INTERVENTIONS
Pharmacotherapy Antidepressants
imperative that the patient and family members understand the possible side effects associated with the drugs being administered, especially the use of antidepressants in patients who are depressed and suicidal (Kazim, 2017). Several studies using randomized controlled trials have shown that treating depression using drug therapy, such as antidepressants, including selective serotonin reuptake inhibitors (SSRIs), has been associated with decreased suicidal ideation
Each patient should be individually addressed to evaluate the safety of the environment into which he or she is returning. In these circumstances, pharmacologic interventions are often employed. Some clinicians and researchers believe that many suicidal patients stand a better chance of recovering from their mental health problems if they at least initially use medication while undergoing therapy (Ax, 2018). If pharmacologic interventions are used in patients discharged to home, it is
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