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Safety Plan: An Evidence-Based Tool for Suicide Prevention


According to the World Health Organization (WHO), every 40 seconds a person dies by suicide somewhere in the world and over 800,000 people die due to suicide every year. When it comes to therapeutic approaches that have shown to reduce suicide attempts, there are only a handful of evidence-based treatments. One of these treatments is cognitive-behavioral therapy (Brown & Jager-Hyman, 2014). A safety plan is a key element of the cognitive-behavioral approaches that has been widely and effectively used for preventing suicide.

In a nutshell, a safety plan is a document that is developed though collaboration between the person at risk of suicide and a treatment provider and consists of a prioritized written list of coping strategies and supportive resources that a suicidal person can use before or during a suicidal crisis (Stanley & Brown, 2008). A study comparing Safety Planning Intervention with usual care found a 45% reduction in suicidal behaviors and the double the odds of suicidal patients engaging in a mental health program following discharge from an emergency department (Stanley et al., 2018). Safety plan is a simple yet effective intervention that is sadly underutilized given that suicide rates have been climbing up globally and in the U.S. The Centers for Disease Control and Prevention (CDC) lists suicide as the second leading cause of death among individuals between the ages of 10 and 34.

Who needs to do a safety plan?

A safety plan is recommended:
  • If you are having suicidal thoughts
  • If you have attempted suicide in the past
  • If you are feeling hopeless
  • If your depression is severe and you have factors that increase the risk of suicide attempt or completed suicide
  • If you cannot identify any reasons to live
  • If you are unsure that you can trust yourself to keep yourself safe

What are the Components of a Safety Plan?

The safety plan developed by Barbara Stanley and Gregory Brown for the U.S. Department of Veterans Affairs has six components (Stanley & Brown, 2008). These are as follows:

1. Recognizing warning signs: These are situations, thoughts, images, moods, or behaviors that immediately precede a suicidal crisis. Questions to elicit these warning signs include:
  • “What do I experience when I start to think about suicide or feel extremely distressed?”
  • “How will I know when the safety plan should be used?”
Examples of warning signs may include thoughts such as, “I am hopeless,” or “I am a failure,” moods such as “Feeling down,” or “Feeling irritable,” or behavior such as “Avoiding other people,” etc.

2. Using internal coping strategies: These activities don’t require you to depend on others and can be used to take your mind off your problem and prevent your suicidal thoughts from escalating. Some strategies for these coping strategies include:
  • Identifying reasons to live
  • Identifying your internal and external strengths
  • Problem-solving a particular situation
  • Challenging irrational thinking patterns such as all-or-none thinking
  • Practicing relaxation techniques or mindfulness 
  • Practicing positive self-affirmations
Once you have decided on your coping strategies, ask yourself:
  • “What do I think is the likelihood that I would be able to do this step during a time of crisis?” The coping strategy should be easily accessible to you without relying on any outside help.
  • “What obstacles might I face when I am doing these activities?” If you do identify some barriers, then either problem-solve or use alternative coping strategies.
3. Utilizing social contacts who may distract from the crisis: This doesn’t involve reaching out to people specifically for help with suicidal crisis but removing yourself from your internal environment and using your external environment as a distraction from your suicidal thoughts and urges. This can be family members or friends or other safe places where socialization occurs naturally, such as coffee shops or places of worship. Avoid environments where alcohol or other substances may be present. Use this strategy if your internal coping strategies haven’t been helpful in decreasing your suicidal thoughts or urges.

4. Contacting family members or friends who may offer help: If your internal coping or social distraction strategies haven’t been effective, then inform family members or friends about your suicidal thoughts. These are people who are supportive of you, understand you, who you trust, and with whom you are most comfortable. Also, ask the people you have chosen whether they would be willing to be your crisis contact in case you have suicidal thoughts or urges. Share about your illness with them and also your feelings so that they are not surprised if they get a call from you. Choose at least three such people to ensure that one is available during a crisis. Have an understanding with these people that they will stay with you until you feel safe or they will get you professional help or take you to an emergency room if you continue to have suicidal thoughts.

5. Contacting professionals and agencies: Prioritize list of mental health or other health care providers you can contact during a suicidal crisis. Also, list agencies that can be contacted, especially during non-business hours when it may be difficult to reach a healthcare provider. For example, crisis line of your local mental health department, the National Suicide Prevention Lifeline, the VA Suicide Prevention Hotline if you are a veteran, or even 911.

6. Making the environment safe: Removing or limiting access to a potential lethal means of attempting suicide is a key component of a safety plan. Examples include:
  • Removing firearms from the home or giving them to your family members or friends for safe keeping. Contacting law enforcement to remove the firearms is also an option.
  • Getting rid of old medications.
  • Asking your family members or friends to regulate your medication by dispensing them to you a week (or shorter) at a time, especially if have had urges to overdose or have done that in the past.
  • Giving your car keys to family members or friends if you have the urge to drive into traffic.

Tips for Implementing a Safety Plan

The best devised safety plans can hit roadblocks. Here are some tips to make your safety plan effective:
  • The most crucial component of a safety plan is the recognition of the early warning signs. You have to spend some time to think about these and write them down. If you are having difficulty with this, ask your family members or friends who are aware of your mental illness and suicidal thoughts if they see any pattern of emotions or behavior before or during a suicidal crisis.
  • Include in your safety plan only tried and tested coping strategies. This is not a time to experiment with a new coping strategy.
  • Safety plan is a living, breathing document that changes when you think it is not working for you. You need to review it periodically and problem-solve any barriers you identify.
  • Keep the safety plan where you can easily access it and also make copies for the people you have listed on the plan.
  • Safety plan is only one part of your overall treatment for mental illness and suicidal thoughts. Continue your treatment with your mental health provider and share your safety plan with them.
  • Don't confuse a safety plan with a "safety contract." A safety contract is simply a signed statement that one writes for a clinician that they will not act on or reach out for help when experiencing suicidal thoughts. There is little evidence that these are even effective (Brodsky et al., 2018).
To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The zero suicide model: Applying evidence-based suicide prevention practices to clinical care. Frontiers in Psychiatry, 9, 33. doi: 10.3389/fpsyt.2018.00033

Brown, G. K., & Jager-Hyman, S. (2014). American Journal of Preventive Medicine, 47(3S2), S186-S194.

Stanley, B. & Brown, G. K. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, DC: U.S. Department of Veterans Affairs. 

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ...Green, K. L. (2018). Comparison of the safety planning intervention with follow-up versus usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900.



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