Brief Interventions to Maintain Safety | Part 1 Suicide Safety Planning
Supporting clients at risk of suicide is one of the most stressful and challenging aspects of clinical practice. The responsibility of ensuring a client’s safety, while recognizing that their actions are ultimately beyond your control, can be overwhelming—even for the most experienced clinicians. The fact is, however, that whether you choose to work with individuals at risk of suicide or not, at some point in your career you will encounter someone who expresses thoughts of suicide, and knowing how to respond in these moments can have a significant impact on outcomes.
Any expression of suicidal thoughts requires a full assessment and risk formulation to determine the most appropriate intervention. For many clients, you may determine that there is no immediate risk of suicide (no acute danger), but suicidal thoughts persist and your role here is to collaborate with your client to maintain their immediate safety while deciding on the next steps in treatment.
Two key interventions that should be implemented with any client at risk of suicide—whether current thoughts of suicide, past ideation, or a previous attempt—are safety planning and restricting access to lethal means. These evidence-based interventions are proven to effectively address the impulsivity often present in suicidal crises, where a person can quickly transition from suicidal thoughts to actions. By creating a suicide safety plan that includes coping strategies and restricting access to lethal means, you can greatly reduce the likelihood of a suicide attempt.
What exactly is a Safety Plan?
A safety plan is a personalized written list of warning signs, coping strategies, and supportive contacts that a client can use during or before a crisis that can aid in reducing suicidal behavior. One of the most well-known and evidence-based safety plans, developed by Barbara Stanley and Greg Brown (1), includes six key areas to address with your client.
When creating a safety plan, it is helpful to explain to your client that thoughts of suicide can be unpredictable in both their occurrence and intensity. These feelings or urges can arise suddenly and lead to impulsive actions, so having thought through ways to distract from suicidal thoughts and access support can be essential to keeping them safe.
Ask your client if they would be willing to develop a plan with you for times they may begin to feel overwhelmed. If possible, provide them with a printed template, or simply a blank page, to write down their plan. You can then work collaboratively to identify the following:
1. Warning Signs: Signs that may indicate a suicidal crisis.
Ask your client to consider ways in which they may think or feel before a suicidal crisis - what do they notice about their behavior? It can be useful to reflect on a recent crisis and identify feelings or behaviors that they noticed as this crisis approached. Were they beginning to isolate, feel depressed, agitated, or emotional? Maybe they began to notice intrusive negative thoughts? Anything that they can describe as an indicator they were not doing well.
2. Coping Strategies: Internal coping strategies that your client can use without needing to contact anyone else.
Ask your client to consider what they can do on their own to help themselves keep safe. This can include soothing activities like taking a shower, going for a walk, or going to a movie. It is important here to pay attention to activities that are realistic and likely. Clients can often list off activities that, in reality, they may never really consider. For example, going to a movie - it's good to ask “When was the last time you went to a movie? Is there a theater near you? How likely are you to do this when feeling down?”
3. Distractions: People or places that can help to distract in a time of distress.
Encourage your client to think of comforting places or social situations, such as visiting a coffee shop or spending time with friends, that could help when feeling stressed. The goal here is to use these people or places to help distract from internal thoughts without necessarily discussing suicidal feelings.
4. Personal Supports: Supportive friends or family members to talk to about thoughts of suicide and to ask for help.
People included on this list should be people with whom your client feels comfortable discussing their thoughts of suicide and asking for help. It’s important to include contact information here, to prioritize the list, and to include multiple contacts if possible. It is also important for your client to let these people know they have been added to their safety plan and that they may reach out to them for support.
5. Professional Supports: Any involved mental health professionals or agencies that your client can contact during a crisis.
Most templates will identify who should be included here. Make sure to include the contact information of treating clinicians, the location of the nearest urgent care or emergency room, and always provide your client with the 988 number where they can access 24/7 support via call, text, or chat.
6. Safe Environment: Ways to reduce access to lethal means.
This final step involves reducing the potential for the use of lethal means in a suicidal crisis. Always ask your client if they own a firearm or have access to other potentially harmful items. The goal here is to remove or secure these means, even if no specific plan has been identified. [also see Part 2]
Implementing the Suicide Safety Plan
Establishing a suicide safety plan is an ongoing process, not a one-time task. After developing the safety plan, it's important to:
DISCUSS with your client where they will keep their safety plan so it is easily accessible during a suicidal crisis.
Many clients now choose to store their safety plan on their phone, ensuring it is always available. If the plan is written out during a session, it is helpful for the client to take a picture of the final plan for quick and easy access. I also keep a copy of this plan for later review and discussion.
GUIDE your client on how to use the safety plan effectively.
For example, if your name is listed as a professional support, you may not want the client to contact you as their first option in a crisis. Discuss with the client how to progress through the steps, starting with recognizing when they are in crisis (Step 1) and moving through Steps 2 to 5 as needed. This approach empowers the client to manage crises more effectively. In cases of acute crisis, clients should understand that they should directly contact 988, call 911, or go to the nearest emergency room.
ASSESS the likelihood that your client will use the safety plan as written.
Talk with your client about how likely they are to implement this plan in a crisis and collaborate to address any potential obstacles. It is important that clients understand the role they play in maintaining their own safety while you work together to address the underlying issues that have led to thoughts of suicide.
REVIEW the safety plan periodically.
Developing the most effective safety plan is a continuous process that should be revisited at future appointments. Follow up with your client to ensure they have kept their plan in the discussed location, recall its contents, have used it as needed, and make any necessary adjustments. Regularly checking in—especially after a crisis—ensures that the plan remains useful and up-to-date.
Summary
Developing safety plans with clients at risk of suicide is established best practice in suicide care and, with practice, the formulation of this plan can begin as soon as you start listening to your client's story:
What am I already hearing about risk and coping strategies as they talk about thoughts of suicide?
Safety planning is a collaborative process, and engaging your client in a conversation about ways to stay safe can itself be an effective therapeutic intervention. Helping your client identify triggers and recognize coping strategies they already possess can serve to empower them and promote a sense of control – assuring them that they have the internal mechanisms to access safety and survive thoughts of suicide.
1. Stanley, B., & Brown, G. (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19, 256-264.
Resources for Clinicians
Stanley-Brown Safety Planning Intervention
This site offers guidance on how to develop a safety plan with clients, along with supporting documentation, forms, and brief training videos to illustrate the essential components of the Safety Planning Intervention.
My Safety Plan
Developed by Vibrant Emotional Health (in support of the Lifeline), this is an online, fillable, and printable form for clients, based on the Stanley-Brown Safety Planning Intervention.
SAMHSA - Safety Plan Template
This template can be downloaded from SAMHSA, but I encourage you also to order the Safety Plan Pad—a small pad of tear-off safety plans (similar to a prescription pad)—which can be very useful in clinical practice for clients to fill in, tear off, and take with them.
Would you like more in-depth training in Suicide Safety?
Join the newsletter to receive FREE access to a chapter of the online course: