Safety Plan

Safety plans as a brief clinical intervention have a long history amongst people working with victims of domestic violence (e.g. Glander et al, 1998) and child abuse (e.g. Lipovsky et al, 1998). Amongst mental health professionals working with suicidal patients, safety plans are considered an important component of a comprehensive treatment plan: the intent of a safety plan is to help patients to lower their imminent risk of suicidal behavior. Henriques, Beck & Brown (2007) describe a safety plan as:

“a hierarchically arranged written list of coping strategies, developed collaboratively by the patient and therapist, which the patient can do if a crisis situation arises. At a minimum, the safety plan should include the telephone numbers of (a) social supports, (b) the therapist, (c) the on call therapist, (d) a local 24-hour emergency psychiatric center, and (e) other local support services that handle emergency calls. It should clearly communicate to patients that appropriate professional help is accessible in a crisis and, when necessary, make clear to patients how that help can be accessed... the patient and therapist collaboratively work to develop specific coping strategies, such as coping cards, relaxation techniques, social supports, and the construction of a “hope kit” that can all be incorporated into a safety plan.”

There is emerging evidence that developing a safety plan is an effective intervention for reducing suicide risk. Stanley, Brown, Karlin, Kemp & VonBergen published a manual describing their Safety Planning Intervention (SPI) in 2008, stating that it takes approximately 20-45 minutes to complete. It provides patients with a specific and prioritized set of coping strategies which can be used in the event of a suicidal crisis, or should suicidal thoughts emerge. In a trial of 1640 patients presenting at emergency departments for a suicidal crisis, 454 were offered standard care and 1186 were offered standard care plus SPI. The SPI was associated with decreased suicidal behavior and improved subsequent engagement with professional services (Stanley et al, 2018).

It is important to note that safety planning is only one component of care for patients who are suicidal. Other important aspects of care include: comprehensive risk assessments, evidence-based pharmacological and psychological treatment, and hospitalization. Clinicians unfamiliar with safety planning should note that it differs from a ‘no-suicide contract’ (a written or verbal agreement between the clinician and patient requesting that the patient refrain from engaging in suicidal behavior). Empirical evidence that no-suicide contracts prevent suicidal behavior is poor (Stanley & Brown, 2012; Rudd, Mandrusiak, & Joiner, 2006) and there is concern that no-suicide contracts may lead patients to withhold information about their suicidal intentions (Rudd et al, 2006; Shaffer & Pfeffer, 2001).

The Safety Plan exercise is best completed with patients following a comprehensive suicide risk assessment. It is most effective for clinicians to adopt a collaborative stance when completing a safety plan. The Safety Plan exercise can be completed in-session, and the clinician can use the attached prompt sheet to help them in guiding the patient through components of (i) recognizing triggers and warning signs, (ii) using internal coping strategies, (iii) using social contacts as distraction, (iv) contacting friends and family for help during a crisis, (v) contacting professionals to resolve a crisis, (vi) reducing access to lethal means, (vii) checking the likelihood that the patient will be able to implement the safety plan.

• Glander, S., Moore, M., Michielutte, R., & Parsons, L. (1998). The prevalence of domestic violence among women seeking abortion. Obstetrics & Gynecology, 91(6), 1002-1006.
• Henriques, G., Beck, A. T., & Brown, G. K. (2003). Cognitive therapy for adolescent and young adult suicide attempters. American behavioral scientist, 46(9), 1258-1268.
• Lipovsky, J. A., Swenson, C. C., Ralston, M. E., & Saunders, B. E. (1998). The abuse clarification process in the treatment of intrafamilial child abuse. Child Abuse & Neglect, 22(7), 729-741.
• Rudd, M. D., Mandrusiak, M., & Joiner Jr, T. E. (2006). The case against no‐suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62(2), 243-251.
• Shaffer, D., & Pfeffer, C. R. (2001). Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 40(7), 24S-51S.
• Stanley, B., Brown, G. K., Karlin, B., Kemp, J. E., & VonBergen, H. A. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, DC: United States Department of Veterans Affairs, 12.
• Stanley, B., & Brown, G. K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.
• Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900.