This is the fourth and final column in this series describing the model for therapeutic risk management of the suicidal patient developed and utilized by the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC). As noted in the first column of this series, all mental health professionals, regardless of discipline or treatment setting, need to be competent at suicide risk assessment and management.1 The first three columns of the series focused on therapeutic risk assessment, with the first column providing an overview of the therapeutic risk management model,1 the second elaborating on the use of structured instruments to augment risk assessment,2 and the third describing risk stratification with respect to severity and temporality.3 This fourth and final column describes the safety planning intervention (SPI), which helps realize the goal of therapeutic risk management of the suicidal patient with a novel intervention.
While other interventions, such as pharmacotherapy and psychotherapy, are important to consider when treating suicidal patients, the SPI is offered as a key component of therapeutic risk management of the suicidal patient, which can be used prior to or in conjunction with these other treatment modalities. Because many mental health professionals are in the practice of using no-suicide contracts, as opposed to safety plans, we first discuss a number of concerns related to the use of no-suicide contracts. We then introduce the SPI as an alternative, provide an overview of the SPI, and offer suggestions for how to successfully implement this intervention with suicidal patients.
In response to identifying that a patient is at risk for suicide, many mental health professionals engage a no-suicide contract with their patient. Although some variability exists, a no-suicide contract (also referred to as a no-harm or suicide prevention contract) will typically entail the patient agreeing to not harm him-or herself in a specified time period.4,5 No- suicide contracts may also provide some guidance regarding what the patient is to do (e.g., call the provider) if the person feels that he or she can no longer abide by the contract.4,5 Although there is no empirical support regarding the effectiveness of no- suicide contracts,5,6 research suggests that up to 79% of mental health professionals report that they use no-suicide contracts.7 In addition, no-suicide contracts tend to be used most frequently with highest risk patients.5 There are medicolegal, provider-specific, and patient-centered reasons why no-suicide contracts are not recommended as a method of therapeutic risk management.
The no-suicide contract is not legally binding and does not offer protection from malpractice claims.8
Patients who sign a no-suicide contract do not actually have any legal obligation to uphold their side of the agreement.9 Furthermore, it is erroneous to believe that a document such as the no-suicide contract can actually prevent a patient from killing him- or herself.9
In addition to not providing mental health professionals with any protection from a medicolegal perspective, no-suicide contracts may have an impact on providers’ behavior in a manner that is inconsistent with the therapeutic risk management model. Simon pointed out that a no-suicide contract may have the unintended effect of providing mental health professionals with a false sense of relief regarding their concern for their patient and may lower their vigilance, despite potentially not having any effect on the patient’s intent to die by suicide.9 He noted that the use of such contracts may reflect clinicians’ attempts to control the understandable anxiety that is often experienced when treating patients at risk for suicide.9 No-suicide contracts are sometimes deployed in settings where little or no therapeutic relationship exists, such as during an assessment conducted in an emergency department by an evaluator and patient who are unfamiliar with each other or upon admission to an inpatient unit. Absent any therapeutic relationship, the notion that a contract/agreement with a stranger will meaningfully mitigate risk in the midst of an acute suicidal crisis is suspect at best, and lacking in evidentiary support. Again, false assurances may do more harm than good.
The use of no-suicide contracts may also be disruptive to an existing therapeutic relationship, because it may be negatively perceived by the patient. A patient may mistakenly interpret the use of a contract as signifying that the provider is only concerned about legal protection rather than genuinely caring about the patient’s safety.4 This perception may be reinforced if the contract appears inflexible and not personally meaningful. Range and colleagues4 suggested that a no-suicide contract could also discourage patients from openly discussing their thoughts of suicide with their provider for fear that they would be violating their contract.
Therapeutic Risk Management via the Safety Planning Intervention
The SPI as developed by Stanley and Brown10 is an alternative to no-suicide contracts that addresses many of the concerns regarding no-suicide contracts described above. It is a collaborative and personally meaningful plan for coping with a suicidal crisis. The SPI has been identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices.11 In addition, the Department of Veterans Affairs requires that a safety plan be created for all Veterans who are identified as being at high risk for suicide.12 The components of the SPI are grounded in both empirically supported treatments and theory related to suicide prevention. Specifically, the SPI is based on cognitive therapy approaches that have been adapted for use with patients at high risk for suicide.10 The intervention is collaborative in nature, which is consistent with the Collaborative Assessment and Management of Suicidality model presented by Jobes.13 The SPI is also consistent with recovery-oriented care, as defined by the Substance Abuse and Mental Health Services Administration.14
A safety plan is a hierarchical list of coping strategies that can be utilized prior to or during a suicidal crisis. Unlike a no-suicide contract, which often only specifies what not to do in the midst of crisis, a safety plan provides concrete steps that can be taken to navigate and survive a suicidal crisis. The development of a safety plan should take place following a thorough suicide risk assessment as detailed in the preceding columns of this series.1–3 A nuanced risk assessment informs the content of the safety plan. For example, in assessing what led up to a suicidal crisis, the provider and patient will have likely identified a number of warning signs that can be included in Step 1 of the safety plan. Patients will likely feel understood and listened to, thereby enhancing the therapeutic relationship, if the provider draws information from the risk assessment throughout the development of the plan (e.g., “Earlier you had identified that your kids are a strong reason for living. Do you think we should include them on Step 3 of your plan?”). A safety plan can be implemented with any patient who is identified as being at risk for suicide, in accordance with the patient-specific information gleaned from the comprehensive suicide risk assessment. The SPI can be implemented in the context of outpatient care and is also appropriate for use in acute care settings (e.g., emergency departments, inpatient psychiatric units).15,16
The safety plan consists of six specific steps aimed at providing a patient with a concrete plan for what to do to prevent or cope with a suicidal crisis. A brief overview of the steps is presented here, but we recommend that readers review the Safety Plan Treatment Manual to Reduce Suicide Risk10 for detailed information about the rationale and instructions for each step.
Introduction of the plan. In our clinical practice, we have found that it is essential to provide patients with a rationale for developing a safety plan. This discussion often leads to a much more collaborative and positive experience for both the patient and provider. For example, one can ask patients to recall the last time they were in a suicidal crisis and ask them to describe their thinking process during that time. Together, the patient and provider can reflect on thoughts and emotions that were likely disorganized and interfered with clear judgment during the acute crisis. They can discuss how difficult it was/is to think of good options when in the midst of a crisis. The provider can then let the patient know that the two of them are going to work together on developing a safety plan, which involves “doing the thinking now,” when more clear-headed and not experiencing chaotic thoughts and emotions. Then, in the future, the patient need only recall that he or she has a safety plan and follow it. Patients typically respond to this type of introduction favorably as it conveys that the provider is genuinely interested in helping them cope with suicidal thoughts and facilitating the identification of strategies to do so, rather than simply expecting that patients don’t act on their suicidal thoughts.
Step 1: Warning signs. The first step of the safety plan involves identifying person-specific suicide warning signs.10 These can be described to patients as their own “red flags” or the way that they know they are heading into a suicidal crisis. Warnings signs are distinct from risk factors in that they are proximal with respect to suicidal behavior.17 The items listed in Step 1 can be images, thoughts, behaviors, physical sensations, or feelings and should be recorded using patients’ own words (e.g., “keyed up” versus “hypervigilant”). The provider advises patients that when they recognize that warning signs are being experienced, it is time to employ the rest of the safety plan.
Step 2: Internal coping strategies. During this step, patients list coping strategies that they can use without contacting another person. The strategies should serve the function of keeping patients’ minds off the suicidal crisis to prevent it from escalating.10
Patients should be encouraged to list strategies that have worked in the past and/or that they have learned in therapy. As with Step 1, the items should be individualized and specific. For example, instead of listing “exercise,” list “go for a run at ‘X’ Park,” thereby enhancing the personalized nature of the plan. It is helpful to remind patients that being specific in this manner when developing the plan saves them from having to do a great deal of thinking later, which can be challenging during a crisis.
Step 3: People and social settings that provide distraction. If Step 2 does not reduce the level of suicidal ideation and/or intent, patients move on to Step 3, in which patients reach out to others or insert themselves in social settings, again for the purpose of distraction from distress.10 Providers should clarify for patients that they are not yet asking for help in this step, but that this is a way to “take your mind off the crisis.” In addition to distraction, this step also serves the function of increasing social connection.
Step 4: People whom I can ask for help. If distraction (during Steps 2 and/or 3) has not resolved the crisis, then it is time to reach out to personal contacts who can be notified of the crisis and the need for help.10 We encourage patients to be thoughtful about who is listed in this step to ensure that this is someone they trust and with whom they enjoy a reliable and reasonably stable relationship.
Step 5: Professionals and agencies I can contact during a crisis. If the crisis persists after the first four steps, Step 5 then involves contacting professionals and agencies for help.10 Patients are encouraged to list professionals, such as their therapist or psychiatrist, and emergency resources, such as a psychiatric emergency department, in this step. In addition, they should list the National Suicide Lifeline (1-800-273-TALK). We have found it useful to discuss with patients what to expect if they contact these resources (e.g., conditions under which emergency response will be activated).
Step 6: Making the environment safe. Step 6 relates to the elimination or restriction of access to lethal means in patients’ environments.10 Providers should work collaboratively with patients to find means restriction solutions that everyone involved is comfortable with. These may include practices such as throwing away excess medications, locking up a firearm, or restricting access to knives. We also encourage patients to think about making their environment safe by increasing cues related to reasons for living in their environment. For example, patients can put pictures of their grandchildren on the medicine cabinet.
Additional tips for developing a safety plan. With respect to implementation, it is suggested that patients review the safety plan daily. This allows them to “check-in” regarding their warning signs every day so that they can catch a suicidal crisis as it is building. It also provides the opportunity to familiarize themselves with the plan so that they can more easily follow it when in crisis. We also recommend that patients share a copy of their safety plan with the contacts listed in Step 4. This provides their support system with a concrete tool for how to assist them during a crisis. Just as suicide risk assessment is a process and should be an ongoing component of clinical care with patients at risk for suicide, so too should the review and revision of the safety plan. If possible, the safety plan should be updated regularly as the patient identifies additional warning signs, learns new coping skills, and contacts and resources change. Providers should also discuss with patients where they are going to keep their safety plan and offer to make multiple copies of the plan for them. Safety plans and therapeutic goals should mutually inform one another. Some patients will struggle to populate aspects of the plan, indicating that they lack any activities that serve as internal coping strategies or have no place they can go to distract themselves during a crisis. Developing skills and/or relationships to populate these items may then become a focus of therapy, thereby helping to develop a more robust safety plan, while also building the skills and supports that will more globally enhance mental health and mitigate long-term risk for suicide.
Safety planning is a critical component of therapeutic risk management of the suicidal patient. From a clinical and medicolegal perspective, we recommend thorough documentation of a comprehensive risk assessment and safety plan for all suicidal patients. Inclusion of a safety plan, rather than a no-suicide contract, in the medical record will demonstrate that the provider has not simply had a patient agree not to harm him- or herself, but instead that the provider has worked with the patient to create a plan for how to do this. The SPI uses a collaborative, individualized, and specific approach to risk management, characteristics that have been identified as key components of suicide risk management.4 The clinical and medicolegal benefits of a well articulated safety plan make safety planning a key ingredient of therapeutic risk management of the suicidal patient.
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