Table 9. Safety Planning Intervention Steps (continued)
4. Contacting family
• Instruct the individual to use Step 4 if Step 3 does not resolve the crisis or lower risk. • Explain that this step involves contacting a trusted family member or friend for support. • Obtain feedback from the individual about the likelihood of doing these activities. • Identify barriers and problem-solve ways to overcome them. • Instruct the individual to use Step 5 if Step 4 does not resolve the crisis or lower risk. • Explain that Step 5 consists of professionals who can provide assistance to the individual during a crisis. • Explain that having access to lethal means places the individual at greater risk for suicide and does not allow enough time to use the coping strategies or sources of support listed on the Safety Plan. • For each method that is identified, determine the individual’s access to the lethal means and collaborate to find voluntary options that reduce access to the lethal method and make the environment safer.
• Ask “Among your family or friends, who do you think you could contact for help during a crisis?” or “Who is supportive of you and who do you feel that you can talk with when you’re under stress or feeling suicidal?” • Ask, “How likely do you think you would be able to reach out to each person?” • If doubt is expressed about contacting others, ask, “What might get in the way of reaching out to this person? • Ask “Who are the professionals and community workers that we should identify to be on your safety plan? • Ask, “What is the likelihood that you would contact these professionals or agencies?” • Express concern about the patient’s safety and explain that making the environment safer will help to lower risk of acting on suicidal feelings. For some individuals who attempt suicide, the interval between thinking about and acting on suicidal urges is usually a matter of minutes. • For each lethal method, ask “What can we do to make the environment safer?” • Ask, “How likely are you to do this? What might get in the way? How can we address the obstacles?”
members or friends who may help to resolve the crisis:
5. Contacting mental
health professionals or agencies:
6. Making the
environment safe and reducing the availability of means to complete suicide:
• If doubt is expressed about limiting access, ask, “What are the pros of having access to this method and what are the cons? Is there an alternative way of limiting access so that it is safer?” Note. Adapted from Stanley, & Brown (2018). The safety planning intervention to reduce suicide risk for people with SMI [PowerPoint slides]. Substance Abuse and Mental Health Services Administration. 62 https://www.nasmhpd.org/sites/default/files/SAMHSA%20SPI%20SMI%20PPT%20final_2.pdf.
The basic steps of SPI involve more tasks than simply completing a safety plan form. These include 62 : • Identify and assess suicide risk. • Obtain the patient’s subjective crisis narrative. • Provide psychoeducation around suicide and introduce safety planning. • Identify warning signs that may indicate the beginning or escalation of a crisis and explain how to follow the steps that allow them to cope with the crisis before acting on suicidal thoughts. • Complete the safety plan (see Figure 1 on the next page for the safety planning document). • Implement the safety plan. • Follow up with the patient to continuously assess their risk for suicide. This plan should be developed collaboratively with the individual. Whenever possible, the patient should complete the form themself, and the healthcare professional should be available to provide clarification and ensure that the plan is achievable. Once the safety plan is completed, review the entire plan with the patient. 62 Inform the patient that it is not necessary to follow all the steps before reaching out for help. The clinician should provide a copy of the safety plan to the patient and discuss its location. At follow-up visits, periodically review the safety plan.
In many cultural and religious groups, mental illness is still considered taboo. Many people who contemplate taking their lives are too afraid to seek help for fear of being ostracized. The lack of public awareness concerning suicide in particular, and mental illness as a whole, only potentiates the problem. 15 Suicide prevention strategies should be unique to the target population and should address differences in patient characteristics, methods of suicide, socioeconomic status, age, and gender. Given that suicide is a complex issue, multiple professionals must be involved in any applied strategies. These stakeholders include policymakers, professionals in health education and law, media, and community members. Caring Contacts One evidence-based intervention that has been shown to support individuals following a crisis event is the “Caring Contacts” program. Caring Contacts is an effective suicide prevention strategy that may be used post-discharge for high-risk individuals and may be scaled to the community’s needs. 64 It is low- cost, and once established, volunteers can manage it. The program involves a clinician or other caring individuals who send eight or more messages of care, support, and connection to an individual with suicidal risk over a year. It may consist of postcards, letters, emails, or even text messages. It helps to keep patients engaged, provides a follow-up for individuals who are challenging to engage, and extends the connection between provider and patient after treatment has ended. 64
Suicide Prevention Strategies
Suicide is preventable with early and timely low-cost interventions. Any efforts to thwart the daunting number of suicides worldwide must be thorough and multifaceted; suicide is complex and multifactorial in its etiology. Given that the etiology of suicide is multifactorial, combining multiple strategies to reduce risk and strengthen protective factors at the individual, relationship, community, and societal levels are required. 60 No single approach is impactful enough to decrease the incidence of suicide. For any suicide prevention strategy to succeed and for the suicide prevention interventions to be appropriately tailored to address each individual’s need, it is critical to fully understand the methods used to attempt suicide. All suicides are preventable. Appropriately implemented interventions at the state, community, and individual levels can help prevent suicides and suicide attempts. Some of these interventions include responsible media reporting, assessing the community for barriers to mental healthcare access, introducing alcohol policies to reduce the irresponsible consumption of alcohol, and educating various groups to reduce the stigma of the topic. 15 Early identification of mental health and substance abuse disorders is critical to any suicide prevention strategy. Additionally, training non- specialized healthcare workers in the identification, assessment, and management of suicide is an effective strategy to prevent suicide. 15
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