coping strategies and a list of individuals or agencies they may contact (Stanley & Brown, 2012). Five steps of safety planning There are five basic steps of the intervention, and these steps should be engaged in sequentially until the suicidal crisis is averted. Table 5 provides an overview of each step for a quick reference. 1. Recognition of warning signs : The first step is to help the patient recognize signs that indicate a suicidal crisis is impending. These warning signs could include “personal situations, thoughts, images, thinking styles, moods, or behaviors” (Stanley & Brown, 2012, p. 258). For example, a patient may identify problematic situations such as arguments with a partner, thoughts such as, “I can't take it anymore,” images of overdosing, depressed or agitated mood, and/or behaviors like drinking more than usual or refraining from social activities. A good review and history of prior crises can help generate a list of thoughts, feelings, behaviors, or images that may trigger suicidal behaviors. This step could essentially be renamed: “When do I need to pull out my safety plan?” This step also includes discarding any unused medications, securing firearms, and identifying other potential methods for suicide and reducing access. 2. Employing internal coping strategies : As noted, “In this step, patients are asked to identify what they can do, without the assistance of another person, should they become suicidal again” (Stanley & Brown, 2012, p. 259). Examples of these strategies include taking a shower, going for a jog or walk, doing a puzzle, partaking in a hobby, playing an instrument, listening to feel-good music or watching a feel- good television program, or playing with a pet. Typically, activities are more helpful if they require attention, are soothing, involve physical activity, foster belongingness, and/or have worked in the past. Clinicians can work with their patient to pick a few activities that seem most helpful and list them in the order the patient would likely try them. Step two identifies internal coping strategies that may have been effective previously in reducing thoughts of depression, loneliness, or suicide. This is the first of the brief lifesaving steps an individual can take when in crisis. As with all of the steps in the safety planning intervention, it is important to help elucidate as many options as possible. Further, clinicians should help patients consider what barriers may exist that would interfere with attempting any of the items on the safety plan or reduce the likelihood of its success. Options should be varied enough that at least one option is available in any situation. For example, going for a walk may be effective during the day or on the weekend, but it may not be the safest approach if a crisis emerges at 2:00 a.m. Realistic alternatives should be available for all situations. 3. Utilizing social contacts as a means of distraction from suicidal thoughts : The next step involves patients identifying people or places where socialization is likely to happen. The idea is that if internal strategies were not successful at alleviating the suicidal crisis, the patient should next try distraction from the suicidal thoughts through socializing. Stanley and Brown (2012) list examples of social contacts such as spiritual centers, coffee shops, Alcoholics Anonymous meetings, and workout classes. Step three is built upon the finding that most suicidal crises are short-lived; identifying distractions can be helpful in getting a suicidal individual through a crisis (Stanley & Brown, 2012). Further, an underlying theme in the National Strategy for Suicide Prevention (U.S. Department of Health & Human Services, 2012) is that connection with others is perhaps the greatest protective factor. Strategies for this step can include entering distracting situations or engaging with individuals with whom the patient can spend time, even if the topic of the suicidal
crisis is not a part of the conversation. The goal is simply to put the suicidal individual in the presence of others, with the hope that a sense of connection will trigger lifesaving cognitions. 4. Contacting family members or friends who may help to resolve the crisis : If the previous three steps have been unsuccessful in reducing the crisis, then patients should reach out to others and let them know that they are in a crisis and need help and support. If possible, the patient should share the safety plan with the individuals named in this step. Step four takes step three further by including people the patient could talk to when feeling down, depressed, or suicidal. There should be as many people as possible on the patient’s list. One concern is that if a patient consistently approaches the same friend when feeling suicidal, that friend may eventually become overwhelmed and start to withdraw. This withdrawal may lead patients to a greater sense of isolation and hopelessness, two feelings suicidal individuals should avoid during a crisis. Additionally, individuals listed in Step 4 should be upbeat and able to help foster a sense of hope. Individuals who are being added to the list should be made aware of their role in the patient’s safety plan, and if they feel unable to be of help during a time of crisis, the patient should seek alternatives. 5. Contacting mental health professionals or agencies : In this step, the clinician and patient work together to create and prioritize a list of professionals or other services that could be helpful to the patient when he or she is in distress. This list could include the patient’s current treatment provider (if he or she has one), contact information for local 24-hour emergency treatment facilities in the area, and local or national services, such as the National Suicide Prevention Lifeline (1-800-273-TALK [8255]) and the Crisis Text Line (741- 741), professional agencies and resources that are available to the suicidal individual at any hour of the day. This section may also include local emergency departments, or 911. 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, and is listed below and in the resource section of this course: https://suicidepreventionlifeline.org/wp-content/ uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf It is also worth reiterating 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 al., 2017).
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