Suicide is a significant public health issue and sessions with suicidal clients are a concerning encounter for most psychologists. Having tools and strategies to mitigate the risk, support the client and alleviate your own personal stress are vital. A version of safety planning in one form or another is utilised by many psychologists to achieve these tasks. This article describes a safety planning tool developed and tested in the United States called the Safety Planning Intervention (SPI). The SPI has shown promising results in several recent studies and is being used in various health settings abroad and more recently in Australia to manage and reduce suicide risk.
Much attention over the past decade has focused on management of mental disorders with suicidality often viewed as part of this constellation. However, Australian suicide rates by and large have not changed significantly across that time, justifying renewed efforts to address suicide risk. Increasingly, suicide risk is being addressed independently, with stand-alone interventions designed to specifically tackle suicidal thinking and behaviour. In the past, no-harm or no-suicide contracts were widely used by psychologists to address suicide risk. However, “the existing research does not support the use of such contracts as a method for preventing suicide, nor for protecting clinicians from malpractice litigation in the event of a client suicide” (Lewis, 2007, p.50). No-harm contracts paradoxically ask a highly distressed client to stay alive without providing the resources needed to do so. A far more practical tool is collaboratively developing a safety plan.
Safety Planning Intervention
The Safety Planning Intervention (SPI) is a systematic and comprehensive approach to maintaining safety for a suicidal client (Stanley & Brown, 2008, 2012; Stanley et al., 2015). Typically, a safety plan is developed collaboratively by the psychologist and client while the client is not in crisis. The text based plan helps the client recognise and identify:
- Personal triggering events and warning signs
- Preferred internal coping strategies
- Social contacts/contexts that may distract from the crisis
- Family members and/or friends who may offer help
- Professionals and agencies to contact for help
- Ways to make their environment safe, and
- Reasons to go on living
Most suicidal crises ebb and flow. Empowering clients by providing them with coping strategies to increase identification of a burgeoning crisis, and management strategies to resist suicidal thinking can reduce suicide risk in the immediate and longer term. Using a standardised technique allows for all clinicians involved with a client to be “on the same page”, facilitating easier and safer transitions between clinicians.
While more research is necessary to establish the efficacy of safety planning, some recent research has shown promising results. Research conducted among military veterans in the US has shown that individuals who were given the SPI along with a brief follow-up phone call, were significantly more likely to attend outpatient therapy following an emergency department admission for a suicide related reason, than those who did not receive SPI (Stanley et al., 2015). Furthermore, preliminary results from another study using the same intervention demonstrated a 40% greater reduction in suicidal behaviours compared to the comparison group who received treatment as usual (Brown, 2015). Moreover, SPI is listed on the US Suicide Prevention Resource Centre Best Practices Register (SPRC, 2016) and is a component of CBT treatments for those who have attempted suicide (Stanley et al., 2009).
When to use safety planning?
Safety planning has a place in any health setting in which clients experience suicide risk. Where there may be ambivalence about living or dying, safety planning may be useful. There is no apparent lower bound of suicide risk that negates the value of a safety plan; even when a client presents with a vague wish to die, with no plan or intent, safety planning may be useful to help contain distress. However, safety planning is most pertinent when a clinician forms a view that there is a concerning risk of suicide. Within traditional mental health settings, such as a private practice or public mental health service, a psychologist and their client are together able to develop a safety plan that most effectively mitigates the client’s risk. Of course, ongoing treatment is likely to be the main factor in reducing suicidal ideation and recovery from mental illness, however this takes time and until then, the safety plan serves to help manage risk and empower a client to cope with suicidal thoughts.
Research suggests that many suicidal individuals who receive a referral for their suicide risk, do not attend scheduled sessions or persist with ongoing treatment (Lizardi & Stanley, 2010; Kessler et al., 2005; Monti et al., 2003). Because the clinician’s first contact with a person at risk of suicide could be the only contact they have, the initial session could be their only chance to influence safety and implement a plan to help reduce risk involved with any further suicidal crises. While it is important to take advantage of this situation and to ensure a suicidal client's wellbeing by developing a safety plan early, this need has to be balanced alongside the goal of fostering a therapeutic relationship. One way to achieve this balance might be to listen for possible safety plan components during the initial session, which could then be integrated into feedback. While feeding back to the client a coherent picture of their experiences in a way that helps the client to make meaning of these experiences, previously noted components of a possible safety plan could be offered as an initial way to help limit further distress or crises. For example, reasons for living may be identified in exploration of suicidal ideation. Taking these organically offered elements and populating a safety plan with the client can ensure that the client leaves the appointment with a tangible, individualised and practical tool to support safety.
Lachlan is a 24 year-old male, who was referred following an attempt to end his own life, after his girlfriend of four years left the relationship. Lachlan had no previous history of mental health difficulties, but reported that his relationship had been shaky for a while. Lachlan stated that he had not been sleeping, had been drinking a lot and experienced unbearable distress at the time of relationship breakdown; he felt that the only solution to end his pain was to suicide. Following a short inpatient stay, Lachlan reported that he and his girlfriend were back together, and that he no longer felt suicidal. However, considering the circumstances of his previous suicide attempt, the tenuous nature of his relationship and his apparent limited capacity to cope with intense distress, Lachlan remained at high risk. Lachlan was referred to a private psychologist, for specific work around coping strategies and his relationship; however, his first appointment was in two weeks. As such, the ward psychologist decided the SPI could support Lachlan in an ongoing way and mitigate risk between discharge and his initial therapy appointment. Lachlan identified relationship issues and increased drinking were key warning signs for him, and recorded several distraction techniques to take his mind off his suicidal thoughts, including playing guitar and computer games. He listed two close mates he could talk to and who had visited him on the ward as well as his Mum and the ward psychologist as support people if his other strategies hadn’t helped. His reasons for living included not wanting to let-down his workmates as well as supporting his mother who has a chronic illness.
App based and on-line safety plans
Traditionally, safety plans are written down on paper and taken by the client at the end of the session (see, www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf). While documented in hard copy, the paper safety plan is open to being misplaced or otherwise unavailable at a time of need. As with many tasks usually performed with paper and pen, online and smartphone app versions are emerging. This is true of the safety plans with app based versions now emerging internationally which have the advantage of being readily accessible and easily updated (see box on right for details on BeyondNow, an Australian safety planning app currently in development).
While it is always ideal for those at risk of suicide to receive professional support, many people in this situation, particularly males, don’t reach out for help (Shand et al., 2015; Player et al., 2015). Safety planning interventions that can be accessed publically, such as online or via apps, might provide some level of support to those who are navigating suicidal ideation on their own. The SPI might even encourage these individuals to seek support from a friend or family member, and bring their attention towards mental health services.
BeyondNow is a safety planning smartphone app and website currently in development in Australia for launch in March of this year. It has been specifically designed with input from Australian clinicians and individuals with lived experience of suicide. Funded by Movember, BeyondNow is a joint project between Monash University and beyondblue.
The aim of the safety planning app is to provide a platform for people to develop their own personalised safety plan on the app or website. BeyondNow allows the user to develop a list of warning signs, coping strategies, reasons for living and ways to make their environment safe via either free-text entry, or by selecting from a range of suggestions. In addition, BeyondNow has in built Australian crisis phone numbers and sections for social support and professional contacts, all of which can be dialed from within the app. The app also includes a “sharing” function in which a copy of the safety plan can be shared via email with important support people.
A trial evaluating the app is currently underway in a collaboration between Monash University and Monash Health in Melbourne.
For more information
SPI is a practical and accessible tool that can be used by psychologists to mitigate risk for suicidal clients. The early use of SPI has the potential to enhance the wellbeing of both client and clinician. An individual’s safety plan often proves to be a road-map for increasing overall mental health in a client. It may encourage identification of emotional and behavioural symptoms associated with stressors, as well as developing proficiency in managing strong emotions using coping strategies. Moreover, finding and seeking out the right people to speak with about stressful events is central to positive mental health. Lastly, use of a safety plan may also facilitate a sense of self-efficacy by providing prompts that clients can use for managing difficult emotions in a self-directed manner.
- Brown, G. K. (2015). Safety planning and structured follow-up: A brief intervention for suicide prevention in emergency department settings. Paper presented at the International Summit on Suicide Research (ISSR), New York, USA. Retrieved from http://suicideresearchsummit.org/science-of-the-congress/plenary/
- Kessler, R. C., Berglund, P., Borges, G., Nock, M., & Wang, P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. Journal of the American Medical Association, 293(20), 2487–2495. doi: 10.1001/jama.293.20.2487
- Lewis, L. M. (2007). No-harm contracts: A review of what we know. Suicide and Life Threatening Behavior, 37(1) 50-57. doi: 10.1521/suli.2007.37.1.50
- Lizardi, D. & Stanley, B. (2010). Treatment engagement: A neglected aspect in the psychiatric care of suicidal patients. Psychiatric Services, 61(12), 1183-1191. doi: 10.1176/appi.ps.61.12.1183
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- Stanley, B., & Brown, G. K. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, D.C.: United States Department of Veterans Affairs.
- Stanley, B. & Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. doi:10.1016/j.cbpra.2011.01.001
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- Stanley, B., Brown, G. K., Currier, G. W., Lyons, C., Chesin, M., & Knox, K. L. (2015). Brief intervention and follow-up for suicidal patients with repeat emergency department visits enhances treatment engagement. American Journal of Public Health, 105(8), 1570-1572.doi:10.2105/AJPH.2015.302656
- SPRC (Suicide Prevention Resource Centre). (2016). Safety plan treatment manual to reduce suicide risk: Veteran Version. Retrieved from www.sprc.org/bpr/section-III/safety-plan-treatment-manual-reduce-suicide-risk-veteran-version