Safety Plan

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Tips to Guide Persons/Families in Development of a Safety Plan
Developing a Crisis Prevention Safety Plan - Some things to think about
Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department
Guidelines for Family Action Plans (21 page PDF)
Crisis Planning Tools for Families: A Companion Guide for Providers (34 page PDF)
Patient Safety Plan Template
Crisis Plan and Working Through Hard Times (25 page PDF)
Post crisis plan form 17 page PDF)
Questions to Ask the Doctor About Medication (3 page PDF)
Information for the Physician (5 page PDF)
Rights and Legal Issues - Sample Crisis Plan

Sample Crisis Plan with Instructions
Blank Sample Crisis Plan

Related topics: Are you feeling suicidal? Attempts, Crisis Text Line, Crisis Trends, Contagion/Clustering, Depression, Emergency Phone/Chat/Text Numbers, Facebook Live , Guns, How to Help, How to talk with your kids about suicide, Mental Illness, Need to Talk?, Online Depression Screening Test , Oregon Suicides 1990 to date, Prevention, Religion, Safety Plan, Secrets No More, 741741, Semicolon Campaign, Stigma, Struggling Teen, Suicide, Suicide Internationally, Suicide Notes, Suicide Resources, Suicide 10-14 Year-Olds, Teen Depression, Teen Suicide, 3-Day Rule, 13 Reasons Why', Veterans, Warning Signs

Step 1: Warning signs (thoughts, images, mood, situation, behavior) that

Tips to Guide Persons/Families in Development of a Safety Plan


Provider/Team Considerations

If the Safety Plan achieves its promise of being person/family-centered, the content will be a good reflection of where the person/family is right now and where they want and are ready to be heading.

The Safety Plan should show:

  • where the family is in its “journey”; and
  • where the individual is in his/her personal recovery “journey.”

Consistent with:

  • Stage of readiness for change/degree of insight into behavior
  • Family's self-defined priorities
  • Natural ecology and culture
  • Degree of comfort and success that has been achieved in managing crisis situations
  • Family's interest in use of formal systems
  • Family's interest in use of natural supports

    Develop a Safety Plan that is sensitive to timing and circumstances for the child/family. It's important to recognize what the family feels is hierarchically important at the time you are assisting in safety planning.

  • If the family is focused on behaviors in the school and they are not readily engaging in conversation about behaviors at home, it is clear where the family is poised for action that can lead to real change. Respect that school behavior is the family priority, even if in their shoes you would prioritize behaviors at home, and develop a Safety Plan around that priority. As school-based behaviors improve, the family may have increasing awareness of, less tolerance for, and be ready to take action on home-based behaviors.
  • If the family is still managing the acute phase of a crisis (for example, hospitalizing a child), it may be disruptive or off-putting to ask the family to engage in developing a comprehensive Safety Plan. Focus on what is meaningful for the family now. The process may be brief and succinct in this instance. It may just involve identifying contact information and when to call for outside assistance. A more comprehensive Safety Plan may be developed at a later point.

    Forcing a Safety Plan on a family when they are not ready or interested is, at a minimum, a waste of time and paper. More importantly, it is a signal that we as providers are off-track in delivering familycentered interventions. It impacts the treatment relationship and the opportunity for real change.

    The Safety Plan cannot be what you as the provider would do in the family's shoes, but what the family members can commit to trying or doing. Culture, beliefs, readiness for change, 156946.28 strengths, barriers, and prior experience will all come into play in the event of a crisis and must be taken into account when creating a usable Safety Plan. For example:

  • If a family's culture is such that they have low to no belief that formal systems or services such as counselors, therapists, social workers or similar providers or agencies can help their family in the event of a crisis or otherwise, the likelihood that they will follow the instructions to call their provider's crisis line is low. Having it on the family's Safety Plan is not helpful if this is not something they are going to do.
  • If a family's culture includes an aversion to police and law enforcement, adding instructions on the family's Safety Plan to call the police in the event of a crisis will likely not be followed.

    The family may not be forthcoming with this information initially, so the provider might use scaling or other methods to determine how likely a family is to follow a given portion of the Safety Plan. For example, you might ask, "How likely are you to call the police in the event that (identified client) threatens to hurt you?" Depending on the answer, other measures may have to be substituted in order to have a Safety Plan that the family is committed to using and that also keeps them safe.

    Plans that are filled with things that you as the provider would do may give you a false sense of confidence that the risk of harm is reduced. If the family won't do it in a crisis, it does not reduce risk of harm and it should not be on the Safety Plan.

    Depending on the age, maturity level, and amount of insight and vested interest in treatment, the persons whose actions are the focus of the Safety Plan will differ.

  • In some cases the child does not agree that he/she has behaviors that are unsafe or that there are things that he/she does that are putting himself/herself and his/her family at risk. In these situations, most or all of the interventions in the Safety Plan will be carried out by the family/caregivers who are willing to take action. The child may not even be aware of the strategies parent(s)/guardian(s) are planning to use.
  • In some cases the focus of the Safety Plan is solely on the goals and actions of the child.
  • If the child is willing to be an active participant, it is important to include the child and give him/her a customized role in the Safety Plan.

    It diminishes the authority of the parent/guardian and the credibility of the Safety Plan to have it filled with actions that a child (or anyone else) is unlikely to take. Attempts to implement this kind of Safety Plan may actually escalate risk in the household rather than reduce risk or unwanted behaviors. That some Safety Plans focus solely on actions of the parent(s) does not in any way suggest that they are to blame. They simply are ready for action while their child is not. As they make strategic changes in their behaviors or responses or take other actions, the child may change in the direction of the desired behaviors as well.

A parent/family may be averse to using a parent/family-based Safety Plan or playing a role in their child/teen/young adult’s Safety Plan. Ask the reason.

For the family who says, "It just won’t work":

I realize you have not bought into this idea, but based on what you have told me, it seems you are not happy with the way things are going now—so what have we got to lose in trying this?

Find out what they want and make the connection between their goal for safety (even if it is small and doesn’t capture the whole issue, i.e., to avoid having to leave work to meet the police at my house) and how their intervention as a parent can make that happen.

For the overwhelmed parent/family:

I see you are investing a lot of time, energy, and stress into the current cycle/system/process that happens during a crisis (for example, going to the emergency room, dealing with police, calling the crisis line, screaming it out with the youth). How about we make a plan where you can invest just a small portion of that energy into some interventions that are more likely to work? Then you can have more time to yourself!

For the parent/family of an older, almost independent teen or a young adult who sees their role as parents/family as reduced to observer vs. intervener:

There are so many factors regarding John’s crisis episodes that are out of your control. So, let’s focus only on those things that happen before and during a crisis event that you can control as the parent (i.e., your reaction to John’s behavior, your decision to have Aunt Laura come over to talk to him when he is starting to get escalated, your leaving the house to walk in the back yard or around the block when he calls you a name to try to engage you in an argument). We can develop a plan to give you to make sure you do just these few things. You can feel good knowing that you did your part, even if John does not do his part of the plan.

Besides considering whether the identified client will be involved in developing the Safety Plan, determining who else in the household will be involved is also important. To increase whole family "buy-in" of the Safety Plan and true family ownership, it can make sense for non-primary adult caregivers who live in the home to have an active role, even if it is just "to gather the other children in the home and take them outside to the yard or the park" when the identified client's behaviors begin to escalate to a certain risk level, or "to take the babies into their mother’s bedroom and put on cartoons for them" when the identified client begins yelling and pounding on the walls throughout the house. This is not only a way to make all adult members of the household feel that they have a say in their family's Safety Plan, but it also helps the primary caregiver by removing the ‘audience’ of other children or other family members so that the primary caregiver can concentrate on implementing the appropriate interventions with the identified client to stop the crisis from escalating.

Younger siblings may also want to participate, even if it is just to "quietly go into your bedroom, close the door, and work on your puzzle" when they hear the identified client start yelling. Usually everyone in the household wants the identified client's behaviors to stop, so if they are willing to have an active role in helping to do so, this may renew the confidence and energy of even the most crisis-oriented families who have been dealing with these behaviors for a very long time.

Setting the Stage for Safety Planning

Introduce the Safety Plan. Talk to the family about developing a Safety Plan and explain that it is meant to be a tool for the family to prevent or better manage the type of crises/risk situations they have identified. The Safety Plan consolidates information on who to call and what a person/family intends to do when crisis situations arise. Show them the template that they can use to develop the Safety Plan – one side with preformatted sections, the other side a blank space for the family to develop something unique. If the child/family is not comfortable with a paper/pencil approach, ask if there are other formats that would be useful. Remember, if the family throws it away, files it away, or otherwise will not think of it once you leave, the exercise is useless.

Figure out who wants to play an active role in developing the Safety Plan.

  • How involved should the child/young adult be? Roll with resistance and acknowledge that it is his or her choice.
  • How involved should the parent(s)/guardian(s) be? Is the desired outcome enhanced or diminished in the eyes of the child, young adult or family by a Safety Plan that lists actions by others?
  • Don't drag anyone to the table. A power struggle is not productive. This is a living, evolving Safety Plan, and there will be future opportunities to engage those family members who may be disinterested now.
  • If the whole family is resistant, figure out what it means. Realign the planning process so that it is a match to what the family is ready for now. Ask the family what is not working about this process?
  • If a family is not ready for much, the Safety Plan should not be much. The choice is theirs to make. Build an authentic relationship that respects where they are now. When they are ready for more, you will be ready to help them.

Get a sense of general preferences when it comes to using resources—does the family lean towards those that are formal, natural, or self-managed?

Often in the field of mental health, providers are oriented towards the use of formal services to solve mental health problems. However, families have unique preferences when it comes to managing a crisis and your understanding of their culture in this regard is important since an authentic Safety Plan will generally reflect those preferences.

Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department


Key Points

Question Can a brief suicide prevention intervention reduce suicidal behaviors and improve treatment engagement among patients who present to the emergency department for suicide-related concerns?

Findings In this cohort comparison study, patients who visited the emergency department for suicide-related concerns and received the Safety Planning Intervention with structured follow-up telephone contact were half as likely to exhibit suicidal behavior and more than twice as likely to attend mental health treatment during the 6-month follow-up period compared with their counterparts who received usual care following their ED visit.

Meaning The Safety Planning Intervention with structured follow-up telephone contact may be an effective brief suicide prevention intervention that can be implemented in emergency departments.

Abstract

Importance Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care.

Objective To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period.

Design, Setting, and Participants Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018.

Interventions The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement.

Main Outcomes and Measures Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge.

Results Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n?=?1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n?=?400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n?=?36 of 1186; 3.03%) than those receiving usual care (n?=?24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P?=?.03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P?<?.001).

Conclusions and Relevance This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.
Source: jamanetwork.com/journals/jamapsychiatry/article-abstract/2687370

 
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