Safety Planning interventions for adolescents

Article in Review: Bettis, A.H., Donise, K.R., MacPherson, H.A., Bagatelas, P. & Wolff, J.C. (2020). Safety Planning Intervention for Adolescents: Provider Attitudes and Response to Training the in the Emergency Services Setting. Psychiatric Services, doi:10.1176/appi.ps.201900563

Safety planning as a tool to help suicidal adolescents
Supporting emergency service providers to set up a safety plan for post-discharge

The creation of a Suicide Safety Plan has been recognised as having beneficial clinical utility for people who are suicidal. A recent study has sought to assess the benefits of providing emergency services practitioners with training in creating and using Suicide Safety Plans for suicidal adolescents.

The Suicide Safety Plan

A Suicide Safety Plan acts as a “roadmap” for people who are experiencing suicidal thoughts by presenting them with information on:
• Warning signs and triggers
• Coping skills to distract
• People to distract
• People for emotional support
• Professional support
• Restricted access to lethal means
• Reasons for living

Suicide Safety Plans have shown to be effective in reducing suicidal ideation and attempts in both adolescents and adults and improving patient outcomes for suicidal people who have been admitted to an emergency service. They are also associated with reduced costs of care. When suicidal patients present at an emergency facility in the United States, hospitals are encouraged to provide information at the time of discharge to reduce future suicide risk. This information could be produced in the form of a Suicide Safety Plan, however, there is currently no standardised approach to these plans within emergency departments.

Methodology

A study to assess the implementation and use of the Suicide Safety Plan intervention was conducted amongst 29 participating medical doctors, clinical social workers, licensed mental health care workers, and qualified mental health providers working specifically with adolescents. Participants completed a pre-training survey, which assessed their attitude and knowledge about Suicide Safety Planning. They were then provided with Suicide Safety Plan Training and asked to complete further questionnaires at the end of the training and at one month and nine-month follow-ups.

Pre-training provider attitudes

Before undertaking the Suicide Safety Plan training, participants indicated a strong desire to learn more about the tool and had a high degree of confidence about their ability to use the tool with adolescents. Most said they although they understood the process, they had not had any specific training in the use of the tool. Some reported concerns that using the tool would be time-consuming, cumbersome or difficult to discuss with a patient’s family in some instances.

Exploration stage

Participants had indicated they were not using a standard approach and were keen to adopt an evidence-based and structured approach. During the first stage of the research, meetings occurred with participants to evaluate the need for Suicide Safety Planning implementation. This involved assessing fit with population needs and exploring readiness for implementation.

Installation

In the second stage, a training plan for participants was developed, and a one-hour, in-person training session was delivered to enhance competence and fidelity with the Suicide Safety Plan model. Internal policies and procedures were also adapted to enable the implementation to occur.

Initial Implementation

After completing the training, participating professionals were asked to put what they had learned into practice. Participants were provided with support and feedback from the research team and the opportunity to raise and discuss any factors that were making it challenging for them to roll out the Suicide Safety Plan. Several common challenges were reported. These included how to best use the tool with young people with developmental disabilities or severe aggression and how to best engage families with the process. As a result of these reports, some modifications were made to the recommended process and the Suicide Safety Plan template itself.

Full implementation

During this final stage, the Suicide Safety Plan intervention was fully adopted and integrated with service delivery. Resources to train new staff in the use of this approach were provided, including a case study video of a Suicide Safety Plan being completed by a professional with a young person and family member.

Post-implementation feedback

Participants consistently indicated that the tool provided common language and structure to help them formalise a process for Suicide Safety Planning. They said that plans “helps parents to know triggers and what to observe at home” and they allowed for “group discussion regarding a plan to go home”. Time remained a concern for providers, especially in situations where patients and families had already experienced lengthy delays in hospital and may not be fully willing to participate in care planning.

Conclusion

Participants in this research supported the use of the Suicide Safety Plan as an acceptable tool in the emergency setting, and their attitudes towards the tool improved as a result of training. Participants reported a strong interest in learning evidence-based interventions before they undertook Safety Planning training, although some were already familiar with the Safety Plan. They recognised the need for the intervention to be incorporated into their care practices for suicidal patients.