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How to Develop a Suicide Safety Plan

20 September 2021
How to Develop a Suicide Safety Plan

Gabriela Khazanov, PhD :
What can you do when a friend or family member tells you they are thinking of suicide? Learning that someone you care about is considering ending their life can be a terrifying and confusing experience. Most people feel at a loss for what to do or say in this situation.
Though some individuals experience chronic thoughts of suicide, a suicidal crisis-an acute period of high suicide risk-is typically short-lived. Additionally, people often feel ambivalent about suicide. While they want to end the psychological pain that they are experiencing, they may also remain aware of the consequences of their death for their loved ones. They may oscillate between resolve to take action on suicidal thoughts and paralyzing fear, or feel torn between a desire to self-isolate and a desire to reach out for help. These overwhelming emotions can make it difficult to plan and carry out coping behaviors.
That's the foundation of the Safety Planning intervention, which Drs. Barbara Stanley and Gregory Brown (2012) developed to help individuals plan for future suicidal crises. The goal of this intervention is to help someone identify tools to protect their well-being when they have suicidal thoughts so that they can "ride out" these thoughts until they resolve or decrease in intensity.
The steps of the Safety Planning intervention are described below. When someone is in crisis, they should proceed through the steps until the crisis resolves or they seek help. If they are very distressed, they can skip the first few steps and immediately ask for help.
We recommend writing down responses to each component on a piece of paper or an app so that the person can access the safety plan easily.
Step 1: Identify warning signs
Ask: "What are your 'red flags' that indicate that you're having a hard time?"
The first step is to identify warning signs that a suicidal crisis may be developing. Being aware of warning signs can help a person recognize early on that they need to use coping skills in order to keep their thoughts and behaviors from escalating. Warning signs may be thoughts (e.g., "I am worthless," "I will never feel better,") emotions (e.g., intense sadness or anger), or behaviors (e.g., strongly considering using substances or acting on suicidal thoughts).
Step 2: Internal coping strategies
Ask: "What activities have you done in the past to distract yourself from suicidal or difficult thoughts?"
The next step is to generate a list of internal coping strategies: things an individual can do on their own to distract themselves from suicidal thoughts and urges. Having a toolbox of coping strategies can help people develop confidence in their ability to manage suicidal thoughts and urges. Examples include exercising, spending time outdoors, writing in a journal, engaging in prayer or other spiritual activity, or listening to upbeat music.
Pro tip: Make these strategies specific and easy to implement (e.g., "I will watch my favorite comedian on YouTube").
Step 3: People and social settings that provide distraction
Ask: "Who could you contact to take your mind off of your thoughts? What places or activities with people may distract you?"
While internal coping strategies can be incredibly helpful in many circumstances, there may also be times when they are not sufficient to prevent suicidal thoughts and behaviors from escalating. In this step, you come up with ideas for people to contact and social settings that could provide a distraction. These options are useful when a person needs to "get out of their head," but may not feel comfortable sharing their emotional state with others. Ideas include meeting a friend for coffee, calling a family member to catch up, attending church, or going to the mall, park, or grocery store for a change of scenery.
Step 4: People I can ask for help
Ask: "Who could you contact to ask for help?"
By this stage, a person has likely tried using coping strategies and connecting with people or social settings that provide distraction, but may find that their suicidal thoughts or urges are too difficult to resist. The goal of this step is to make a list of two to three people the person can reach out to for help and to list their phone numbers (even in today's electronic world, it's important to have these numbers written down. A person in crisis may delete phone contacts or may not be able to access their phone during a crisis).
Pro tip: Think carefully about whom to include in this list. Ideally, it would include others who know the person well and can be trusted to respond with compassion and empathy rather than criticism or judgment. Since reaching out in the midst of a crisis can be difficult, it can help to plan for what the individual would feel comfortable saying when they reach out for help (for example, "I'm reaching out because I'm really struggling right now and I was wondering if you could listen and help me think through what to do next.").
Step 5: Professionals or agencies I can contact during a crisis
Ask: "Who could you contact in a crisis?"
If the person is receiving care from a mental health professional (e.g., a psychologist, psychiatrist, social worker, or counselor), contact information for that person should be included in the safety plan. Be sure to note times the clinician may be unavailable. For example, they may only take calls during business hours, or may have a separate phone line for clients to get in touch in case of emergency.
You should also include contact information for emergency resources in the individual's community, such as a local emergency room or a 24-hour psychiatric emergency care service. The National Suicide Prevention Lifeline, which is available 24/7, is another valuable resource (1-800-273-TALK[8255]).
Step 6: Making the environment safe
One of the most important steps is to make sure the individual does not have access to means of ending their life. Though this conversation can be scary, it is useful to gently ask the person if there is anything in particular that they have thought of using to harm themselves (such as a gun, rope, razor blade, or stockpiled medication), and how easy it is for them to access that item. Making it harder to access these means can considerably decrease the risk of a suicide attempt. For example, someone is more likely to use medications to overdose if they have a stockpile of extra medication at home than if they have to go to the store to buy medication. Increasing the difficulty of making a suicide attempt provides extra time for the person to step back and reconsider their decision.
If the person has ready access to lethal means and you feel comfortable doing so, you can offer to temporarily hold on to those items until the crisis has resolved.
A final note
While we described evidence-based strategies to help individuals experiencing thoughts of suicide, we also want to emphasize how healing and reassuring it can be to respond to someone in crisis with compassion and understanding instead of judgment or disapproval. Even if it feels like you are powerless to change the individual's situation, accepting them as they are and listening with empathy creates a powerful lifeline that can make all the difference.
We encourage people experiencing suicidal thoughts to seek professional help. If you are experiencing suicidal thoughts, please contact the National Suicide Prevention Lifeline (800-273-TALK[8255]).
If you are concerned that an individual is an immediate threat to themselves or someone else, do not leave them alone and call 911 or go to your local emergency room.

(Gabriela Khazanov, Ph.D., is a psychologist and postdoctoral fellow at Philadelphia's Crescenz
VA Medical Center).

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