Safety Plan
Sample Crisis Plan with Instructions
Step 1: Warning signs (thoughts,
images, mood, situation, behavior) that When COVID-19
Threatens Your Suicide Safety Plan I have lived with major depressive disorder (MDD) and suicidal ideation for the majority of my life. Since high school, I have convinced myself life is worth living because of the future. The vague possibilities of “the future” were never enough, though, so quickly I started using concrete future plans as my safety plans: stay around for a concert, for a trip, for an event or to see certain people. The idea was to always have something in the future I was looking forward to and something after that so I wouldn’t be left with nothing once that day passed. There have been canceled plans or events before that were road bumps along the way, but I always had multiple other things lined up and could grieve the small loss and pull myself back into the thought process life is worth living. But, everything has changed now. The coronavirus (COVID-19) — a new-to humans virus that causes respiratory infection and can lead to serious or fatal health complications — started a global pandemic, the United States went into a stay-at-home order and events started to be canceled. It started small.
My depression felt the blow of things I had been looking forward to for months, but there was a perceived end in sight. Things will be OK, we just have to get through a few weeks or a month without seeing friends or going places. I reassure myself over and over again I have bigger things ahead to look forward to. I’m put on a two-week medical isolation and have to learn what it means to deal with mental health and depression while stuck at home with just myself and my thoughts 24/7 without the ability to run to friends for support. The safer-at-home order extends in Los Angeles and more events are canceled. No birthday party. No bars open for my yearly trauma anniversary tradition of going out dancing with friends who make me feel safe and loved. No road trip. I tell my therapist about the difficulty I’m having and we start developing alternative coping strategies, but the losses are hitting harder and harder with every single additional one. Safer-at-home gets extended again and more safety measures are put into effect.
I can’t explain how much it hurts. How do I explain that feeling of questioning if I should be alive or if I have life to look forward to? I wish I could explain how much it hurts. I hope you don’t know how much it hurts, but if you do, you are not alone in this. My head starts cycling through the same thoughts and questions over and over. When will things be “normal” again? Will things get back to “normal” or is society changed forever? Can I risk picking something even further in the future to look forward to when it could get canceled sooner than I think? Will I be able to pull myself up from that loss? Is it ever going to get better? Am I ever going to get better? How do I stay alive when how I’ve learned to convince myself to do so has been pulled apart and made utterly useless in a matter of weeks? I don’t know what I’m doing. I don’t know how to make suicidal thoughts stop or make depression not feel debilitating. I sure as hell can’t stop a disease or a pandemic. But I can continue to do what I’ve always done:
I’m learning to be more honest about the days I’m not OK and have a list of trusted friends I reach out to in the moments I feel the crash of not having my “normal” safety plan. I work on building new, entirely different safety plans. I am learning to be OK with looking forward to smaller things like a cup of coffee the next day, wearing my favorite socks, trying to teach my cat a new trick, petting my cat, talking to my therapist next or FaceTiming a friend. I am learning to try to reframe the things that were seemingly meaningless before being looked at with a little bit of hope now. I’m learning how to tell the appropriate people truly how I’m feeling and the risk factors at play. I’m still not sure life is worth living, but I know I do not want COVID-19 to be the reason I choose to end my life. I still have thoughts of wanting to die daily, but I’m choosing to fight for an alternative, maybe not forever, but at least for now. There is no “one-size-fits-all” safety plan that can keep us all alive or convince us it’s worth it, but I’ve been learning there’s more than one safety plan that can work. So if COVID-19 or anything else has compromised or obliterated your safety plan, please make a new one. If your brain won’t let you make one yourself, connect with professional and/or personal help that can assist you in doing so. We can all make it through this and everything else life is throwing at us, but we can’t do it alone. Suicide thrives on isolation. So, we can be physically distant for the safety and well-being of all, but we need to be more emotionally connected and honest than ever. Reach out to your communities and/or find new ones online. I promise there are people who will walk through this with you and root for you, you may just not know them yet or they may not know you’re needing more support. You can call bullshit on all of this, but I’m putting out love and energy for all of us to make it through and will personally root for anyone who reaches out. We can do this y’all, so let’s kick ass together. Struggling with your mental health due to COVID-19? Check out the following articles from our community:
Resources If you or someone you know needs help, visit our suicide prevention resources. If you need support right now, call
the National Suicide Prevention Lifeline at 1-800-273-8255,
the Trevor Project at 1-866-488-7386 or reach the Crisis
Text Line by texting “SOS" to 741741. Tips to Guide
Persons/Families in Development of a Safety Plan 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:
Consistent with:
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.
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 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. A suicide safety plan should include the following elements:
|
