Use of Suicide Safety Plans among clinicians

Article in Review: Moscardini, E., Hill, R., Dodd, C., Do, C., Kaplow, J. and Tucker, R. (2020). Suicide Safety Planning: Clinical Training, Comfort and Safety Plan Utilization. Environmental Research and Public Health, doi:10.3390/ijerph17186444

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The creation of a Suicide Safety Plan is one of the most widely used preventive interventions for reducing suicide risk. The Suicide Safety Plan is developed collaboratively by a patient and therapist and outlines a number of proposed steps or actions which the patient can take during suicidal episodes. The steps are arranged to address the risk that is intensifying. Key steps typically include identification of:

• Warning signs or triggers
• Internal coping strategies
• Social contacts
• Supportive contacts
• Emergency services
• Steps to minimise the ability to act on suicidal thoughts, including removal of means

A slightly modified approach is also undertaken in Crisis Response Planning in which patients detail:

• Personal warning signs
• Self-management strategies
• Reasons for living
• Social supports
• Crisis supports

This model excludes coverage of the removal of means, and for these reasons, therapists may choose the Crisis Response Planning approach if they don’t feel comfortable discussing means safety with patients, or if time is limited.

Benefits of Suicide Safety Planning

There is positive evidence for Suicide Safety Planning. In one study, patients who received safety planning intervention in an emergency department setting, along with a follow-up phone call were nearly half as likely to make a suicide attempt in the six months following the initial hospitalisation. While the data in support of Suicide Safety Planning is promising, the effectiveness of safety planning could be impacted by factors related to how and by whom the plan has been created.

Variables ineffectiveness of Suicide Safety Plans

Variables influencing the effectiveness of the plan will include details and content of the plans, as well as by personal factors related to the therapist provider. Better quality safety plans ensure coverage of each of the key strategy types proposed, and are more specific in relation to actions to be undertaken. There is a likelihood that personal factors related to individual therapists will impact the creation of the plan. For example, it has been demonstrated that the more religious a therapist is, the higher the likelihood they will believe a patient requires hospitalisation during episodes of suicide risk.

Understanding the therapist’s use of Suicide Safety Plans

While research is promising, comparatively little is known about the use of Suicide Safety Planning in clinical settings, and there have also been studies that seem to be contradictory in terms of how beneficial practitioners believe safety planning to be. This study sought to better understand clinician’s familiarity with Suicide Safety Planning, its various elements and the circumstances in which they elect to use this approach. A total of 119 participants involved in the study, a majority of whom were women (74%)and psychologists (34%) in outpatient/ private community clinics (49%).

Findings

A majority of respondents (87.9%) indicated they had received training in safety planning, with just over half reporting this training occurred as part of their formal training. A majority of respondents felt very confident (43.7%) or somewhat confident (45.4%) with Suicide Safety Planning techniques but a majority (68.1%) also indicated a desire for additional training.

When asked how often they included various recommended elements of the safety plan model in an individual Suicide Safety Plan, the most frequently included sections were:

• Emergency resources/ contacts
• Individual coping skills
• Social coping skills/ social distraction
• Social help-seeking
• Means restriction
• Physic al reminders- reprinting and keep a copy of the plan
• Individual warning signs and triggers

Less frequently used elements were instruction on the use of the plan, use of a safety plan template and practicing the safety plan in session. Suicide Safety Plans were most commonly used when patients have:

• Thought about ending their life by suicide
• Identified a method for suicide and had thought of dying by suicide
• Previously made a suicide attempt and is having thoughts of suicide

A minority of clinicians use the tool with all patients (11.5%)

The study also sought to identify the impact of personal experiences on the clinician’s comfort with or decision to use Suicide Safety Plans. Having a patient die by suicide was not related to completing safety plans, nor was personal exposure to suicide.

Conclusion

This study found that therapists are commonly comfortable with creating Suicide Safety Plans but a majority also suggesting a need for more training in how and when to use the tool. Options for therapists such as online training resources (such as the Stanley and Brown online toolkit) are recommended. Further opportunities are noted for encouraging patients to share their plans with family and friends and building overall community awareness about the use and benefits of Safety Plans for at-risk individuals.