Developing a treatment and services plan
- Creating a safety plan
- Preparing a commitment to treatment statement
- Developing a crisis response plan
- Identifying tools for means restrictions
Creating a safety plan
A safety plan outlines a prioritized, specific set of coping strategies and sources of support that patients can use during a suicidal crisis or in the period leading up to it. The plan is developed collaboratively with the patient using the patient's own words so it is easy to understand. It takes 20 to 45 minutes to complete a thorough safety plan.
The intent of the safety plan is to lower imminent risk of suicidal behaviour by prompting the person to use identified coping strategies and supports. The safety plan also serves a therapeutic purpose. Trying out the coping strategies, social support activities and help-seeking behaviours outlined in the plan gives the person the opportunity to evaluate the strategies so in the future they can use those that are most effective and avoid those that are not (Stanley et al., 2009; Stanley & Brown, 2008).
Safety plans are especially useful for patients who live in rural communities because they may not seek treatment following a suicide risk assessment or may experience delays between assessment and accessing treatment. Given that suicidal crises may be short-lived and can reoccur, an intervention such as a safety plan that gives the individual immediate support during a crisis is particularly useful in rural communities, where health care services may be scarce (Stanley & Brown, 2012).
Basic components of a safety plan
- Recognize warning signs that are proximal to an impending suicidal crisis.
- Identify and employ internal coping strategies without needing to contact another person.
- Use contacts with people as a means of distraction from suicidal thoughts and urges (e.g., going to a healthy social settings without discussing suicidal thoughts).
- Contact family members or friends who may help to resolve a crisis and with whom suicidality can be discussed.
- Contact mental health professionals or agencies.
- Reduce the potential use of lethal means.
The section below outlines each step of the safety plan. The person begins by recognizing when they are in crisis (Step 1), and then proceeds to Step 2. If the strategies outlined in Step 2 fail to decrease suicide risk, the plan proceeds to the next steps.
Step 1: Recognize warning signs
Work with the patient to identify thoughts, images, thinking processes, moods and behaviours that precede suicide-related behaviour. Ask:
- How will you know when the safety plan should be used?
Step 2: Use internal coping strategies
Identify internal coping strategies the patient has used in the past or is interested in using in the future. Ask:
- What can you do on your own if you become suicidal again, to help yourself not to act on your thoughts or urges? What activities could you do to help take your mind off your problems even if it is for a brief period of time?
Evaluate the likelihood that the patient will use such strategies. Ask:
- How likely do you think you would be able to do this step during a time of crisis?
Identify barriers to engaging in these coping activities and discuss ways to overcome them. Ask:
- What might prevent you from thinking of these activities or from doing them?
Step 3: Use social contacts to distract from suicidal thoughts and provide support
When patients feel suicidal, socializing with friends of family without explicitly informing them of that suicidal state may serve as a distractions from those suicidal thoughts. Social contacts may include social groups (e.g., friends, family) or social places (e.g., coffee shops, places of worship).
The safety plan prioritizes the list of contacts, and phone numbers or locations may be included. Ask:
- Who helps you feel good when you socialize with them? Who helps you take your mind off your problems at least for a little while?
- Where can you go where you´ll have the opportunity to be around people in a safe environment?
Step 4: Contact family or friends to help resolve a crisis
Identify who the patient can contact when they explicitly indicate that they are in crisis and need help. Ask.
- Among your family or friends, who do you think you could contact for help during a crisis? Who is supportive of you and who do you feel you can talk with when you are under stress?
Ask the patient about the likelihood that they would contact these individuals and have the patient identify potential obstacles and ways to overcome them. If possible, someone close to the patient with whom the safety plan can be shared should be identified. This person should be named in the plan.
Step 5: Contact professionals and agencies
If Steps 1-4 do not resolve the crisis, Step 5 emphasizes that professional help is available for dealing with a crisis and involves contacting a health care professional or service for support. Identify who the patient can contact and indicate how they will access the service. Ask:
- Which mental health professionals should we identify in your safety plan? Are there other health care providers?
Examples of professional supports include mental health clinicians, 24-hour local urgent care facilities or emergency departments and suicide hotlines.
Step 6: Reduce the potential for use of lethal means
Examples of reducing access to means of suicide include storing medication safely, implementing gun safety procedures or restricting access to knives. Deciding whether to remove the means or restrict access to it will depend on the lethality of the method. Ask the patient which means they would consider using during a suicide crisis and work together to identify ways to secure or limit access to those means. Ask:
- What means do you have access to and are likely to use to make a suicide attempt?
- How can we go about developing a plan to limit your access to these means?
Routinely ask whether the patient has access to a firearm and whether it is considered a "method of choice," and make arrangements for securing the weapon. For methods with lower lethality, such as medication or other drugs, ask the patient to remove or restrict access to these methods themselves before they are in crisis. Note the specific actions that are necessary to make the patient's environment safer in the safety plan.
Implementing the safety plan
Assess the likelihood that the patient will use the safety plan and problem solve if there are obstacles. Ask:
- How likely is it that you will use the safety plan when you notice the warning signs we have discussed?
- What might get in the way or serve as a barrier to your using the safety plan?
- Let´s discuss some ways to deal with these barriers so you will be able to use the safety plan when it would be most helpful for you.
Discuss where the patient will keep the safety plan and how it will be located during a crisis.
Evaluate the appropriateness of the format given the patient's capacity and circumstances.
Review the plan periodically when the patient's circumstances or needs change.
A commitment to treatment statement (CTS) is an agreement between the patient and the clinician in which the patient agrees to make a commitment to living (Rudd et al., 2006). The patient makes this commitment by:
- identifying the roles, obligations and expectations of both the clinician and the patient in treatment
- communicating openly and honestly about all aspects of treatment, including suicide
- accessing identified emergency services during crisis that might threaten the patient's ability to honour the agreement.
The CTS does not restrict the patient's rights with respect to the option of suicide; rather, the patient is making a commitment to living by engaging in treatment and accessing emergency services if needed.
It is recommended that the CTS always be handwritten and individualized by the clinician. It should always include a safety or crisis response plan. It is important to identify any time restrictions imposed by the patient (e.g., duration of treatment: 1 week, 1 month, 1 year). An example of a CTS can be found here.
A CTS differs from an informed consent statement. It targets the patient's motivation and commitment to the treatment process, outlining core elements and expectations. The CTS can be very brief (see the example here), or it can be more detailed, depending on the patient and the context.
A CTS is not a no-suicide contract, which is not recommended (Rudd et al., 2006). A no-suicide contract is an agreement between the patient and the clinician that stipulates that the patient may not harm himself or herself and must seek help when in a suicidal state and feels unable to honour the commitment. No-suicide contracts have the following problems:
- There is a lack of empirical evidence supporting the effectiveness of no-suicide contracts in preventing suicide.
- The term "contract" implies more concern for the medicolegal aspects of practice than for the clinical process.
- No-suicide contracts may limit open and honest communication because the patient and the clinician and appear to free the clinician from blame for any bad treatment outcome.
A crisis response plan is smilar to but less thorough than a safety plan. It gives the patient specific instructions about what to do during crisis. The steps in the plan can be written on a small sheet of paper or card. The first steps in a crisis response plan usually involve self-management in an effort to build the person's crisis management skills. The final few steps include external intervention, including who to telephone before accessing the emergency room.
A list of tools for restricting means for suicide-related behaviour can be found in Bryan et al. (2011). Tools include a means receipt and a crisis support plan.
Brown, G.K. & Stanley, B. (2009). Safety Planning Guide: A Quick Guide for Clinicians. Boulder, CO: Western Interstate Commission for Higher Education & Suicide Prevention Resource Center
Bryan, C.J., Stone, S.L. & Rudd, M.D. (2011). A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research and Practice, 42, 339-346.
Rudd, M.D., Joiner, T.E. & Rajab, M.H. (2004). Treating Suicidal Behavior (2nd ed.). New York: Guilford Press.
Rudd, M.D., Mandrusiak, M. & Joiner, T.E. (2006). The case against no-suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62, 243-251.
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. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256-264.
- The Suicide Risk Assessment and Management Toolkit
- Attitudes and approach
- Understanding suicide
- Collecting accurate assessment information
- Formulating suicide risk
- Developing a treatment and services plan
- Managing care for suicide-related behaviour
- Understanding legal and regulatory issues around suicide
- Tools for assessing suicide risk and managing suicide-related behaviour