Crisis Hotlines Crisis telephone helplines, or crisis hotlines, are a valuable resource in suicide prevention on a public health level. There is substantial information that helplines reduce distress and suicidal behaviors in many callers. Crisis lines, available 24 hours a day, provide immediate access to crisis intervention, particularly to those unwilling or unable to have a face-to-face interaction with a mental healthcare provider. Crisis lines, such as those in Washington State, are heavily used. Between October 1, 2014, and September 30, 2015, 46,633 calls to the National Suicide Prevention Lifeline came from individuals in Washington State. Of those 46,633 calls, 22,936 were from individuals who used the Veterans Crisis Line for help 15 . Raising awareness of such crisis resources needs to begin in K-12 schools and higher education and be displayed in multiple public locations, including billboards, public transportation, and media outlets. 15 In addition, crisis line information and materials should be available in primary health care, behavioral health care, and emergency department settings. There are no randomized controlled trials of suicide crisis lines, partly due to the difficulty of conducting such studies ethically; however, an evaluation conducted in 2018 of the Substance Abuse and Mental Health Services Administration (SAMHSA) Lifeline found that 80% of callers interviewed six to twelve weeks after their initial call said the follow-up calls kept them from dying by suicide, provided them with hope, made them feel
cared about, and connected them to other mental health resources. 61 Crisis hotlines play a significant role in intervening during an individual’s crisis. Hotlines, which provide 24-hour service with referrals and resources, have demonstrated reducing suicide attempts while connecting the individual with community resources for follow-up. Suicide hotlines provide the connectedness that research shows is an influential protective factor in preventing suicide. 15 Safety Planning Intervention The second highly effective approach to prevent suicide is implementing a Safety Planning Intervention (SPI). This plan is a brief 30-to-45- minute clinical intervention conducted when an individual is identified with a risk for suicide. It is a collaborative effort between a treatment provider and a patient and results in a written list of warning signs, coping strategies, and resources to use during a suicidal crisis. 62 The premise of this intervention is that if individuals are provided tools that enable them to resist or decrease suicidal urges for brief periods, the risk for suicide is likely to decrease. The target population for an SPI evaluation is those at increased risk for suicide but do not need immediate rescue.
Patients at this level of risk may have 62 : • History of suicidal behavior (e.g., plans/ preparations for suicide, suicide attempts, aborted attempts,). • Recent history of SI. • Otherwise determined to be at-risk for suicide. This intervention aims to provide people who are experiencing suicidal ideations with a specific set of concrete strategies to use to decrease the risk of suicidal behavior. The safety plan includes a collaboratively identified coping strategy and a list of individuals or agencies that may be contacted during a crisis. It prioritizes relying on internal, individual resources and expands to include resources that include the participation of others or other external resources. 62 In 2018, Stanley and Brown published an article in JAMA Psychiatry comparing SPI with follow-up versus usual care of a suicidal patient in the emergency department. They found that SPI with follow-up resulted in 45% fewer suicidal behaviors over a period of six months. 62 See Table 9 for an in-depth review of each of the Safety Planning Intervention Steps.
Table 9. Safety Planning Intervention Steps
STEP
GOALS
COMMUNICATION
1. Recognizing the
• Identify warning signs that may indicate the beginning of worsening of a crisis. • Understand how identifying warning signs provides an opportunity to cope before acting on suicidal urges. • Explain the purpose of coping strategies is to: 1) help take the individual’s mind off of their problems to prevent worsening of suicidal thoughts; and 2) prevent the individual from making a suicide attempt without contacting other people. • Help the individual recognize internal coping strategies. • Identify barriers and ways to overcome them. • Instruct the individual to use Step 3 if Step 2 does not lower risk. • Identify other people and social settings that provide distraction. • Obtain feedback from the individual about the likelihood of doing these activities. • Identify barriers and problem-solve ways to overcome them.
• Ask “What were the warning signs that you experienced during the crisis?” or “How will you know you are in a crisis and the safety plan should be used?” • If the warning signs are vague, ask the patient to be more specific so they are more likely to recommend the beginning signs of a crisis. • Ask “What have you done in the past to take your mind off your suicidal thoughts without contacting another person? What activities could you do by yourself to help take your mind off of your problems even if it is for a brief period of time?” • If the individual cannot think of any distracting activities, provide suggestions. • Ask “How likely do you think you would be able to do this during a time of crisis?” or “Is it feasible?” If there is doubt, ask “What might stand in the way of you thinking of these activities or doing them if you think of them?” • Ask “Who can you contact who helps you take your mind off your problems or helps you feel better? You don’t need to tell these people that you are feeling suicidal. We just want to identify people who can take your mind off your problems even for a brief time.” • Ask, “What public places, groups, or social events help you to take your mind off your problems or help feel better?” • Ask, “Sometimes when people are feeling really upset, they don’t want to talk to other people. However, sometimes just getting out and being in a place around other people can help. Can you think of places you could go where you wouldn’t have to be alone?” • For each response, ask, “How likely do you think you would be able to talk with someone/go somewhere during a time of crisis?” “Is it feasible and safe?”
warning signs of an impending suicidal crisis:
2. Using your own
coping strategies:
3. Contacting others in order to distract from suicidal thoughts:
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