Table 4: Safety Planning Intervention Step 1. Warning Signs that a Crisis May Develop: • What are the thoughts, feelings, images, behaviors, and/or situations that precede suicidal thoughts or behavior? • “When do I need to access my safety plan?” Step 2. Internal Coping Strategies: • “What can I do to take my mind off my problems without having to contact others?” (e.g., relaxation, listening to music, and going for a walk) Step 3. People and Social Situations that Provide Distraction: • “Who can I hang out with when I am feeling down, depressed, or suicidal?” ○ Write down names and phone numbers for all possible contacts. • “Where can I go to hang out that will prevent me from being alone when I am feeling down, depressed, or suicidal?” ○ Write down names of places. Step 4. People Who can be Accessed in a Time of Crisis: • Write down names and phone numbers for people who the client can contact when feeling down, depressed, or suicidal. ○ This should include upbeat and positive individuals who can provide a sense of hopefulness. Step 5. Professionals or Agencies that can be Contacted During a Crisis: • Write down the names and phone numbers for all contacts. ○ Therapist/Clinician (Include any pager numbers or after-hours numbers).
○ Local crisis centers/urgent care centers. ○ National Suicide Prevention Lifeline (1-800-273-TALK/1-800-273-8255. ○ Local emergency department (Write down address). ○ 911.
Note : Adapted from Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version, by B. Stanley and G. K. Brown, 2008, New York, NY: New York Suicide Prevention Center, Department of Psychiatry: Columbia University & New York State Psychiatric Institute; and “Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk,” by B. Stanley and G. K. Brown, 2012, Cognitive and Behavioral Practice, 19 (2), pp. 256- 264. 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 (Pauwels et al., 2017). Patients can keep these cards handy to consult as needed, and in recent years digital crisis coping card smartphone apps have been created (Bush et al., 2017; Pauwels et al., 2017). Box 3 outlines the steps for creating a crisis card.
Box 3: Steps for Creating a Crisis Card 1. Explain the rationale to the client : 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 client 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). See Appendix A and Resources for other ideas on pleasant events for adults. ○ 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. 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:
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Book Code: SWUS1524
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