Mental Health Safety Planning

Shelley R. Upton, PhD

Content Warning: This blog contains potentially disturbing and triggering content. Before continuing, please be aware that the author writes about suicide and self-harm.

As a mental health professional, keeping my clients safe is my highest priority. How can you help your loved ones and your clients stay safe? If we determine that someone is at-risk for hurting themselves or dying by suicide, we create something called a “Safety Plan”. When we talk about safety planning, we generally mean reducing the risk of harm to oneself. If someone is a danger to themselves, they may be at-risk for self-harm or suicide. Sometimes a person may hurt themselves without the intent to die. We might call this self-injurious behavior (SIB) or non-suicidal self-injury (NSSI). It’s important to first recognize that there is a continuum of risk. (Please note: it’s important to consult a mental health professional to conduct a risk assessment if you’re worried about someone’s level of risk.)

Low Risk: If someone is passively thinking about dying (e.g., “Things would be easier if I could go to sleep and never wake up”), but has no other risk factors (more on those later). These passive thoughts are called “passive ideation”.

Moderate Risk: Someone may be at moderate risk of harming themselves if they have more active thoughts of dying. For example, “I want to kill myself”. These active thoughts are called “active ideation” and indicate that someone has desire to kill themselves. Someone at moderate risk may also be thinking about ways they might kill themselves (we call this a suicide plan).

Severe Risk: If someone has active thoughts of dying or wanting to kill themselves, has a plan, and also has started preparing to carry out their plan (e.g., buying a firearm, hoarding pills), then we might consider them to be at severe risk. Someone at this level may also have other risk factors.

Extreme Risk: We consider someone to be at extreme risk of suicide if they have active ideation, have detailed, specific plans, and has made all preparations necessary.

There are several other risk factors that may make someone more likely to attempt suicide or to die by suicide. These include: capability for suicide (e.g., owning a gun, being fearless about death), previous suicide attempts, and recent life stressors (e.g., loss of job). Additionally, if someone believes they are a burden to others, has little social support, and/or feels hopeless about the future, they may also be at higher risk to themselves.

So how do we help plan for safety? Fortunately, there are multiple ways to do this so we can keep our loved ones safe. Mental health professionals will work with you to create a Safety Plan if you or your loved one is at risk for suicide. This plan will have the level of risk noted and ways to reduce risk and promote coping.

The first component of a safety plan is “means restriction”. This is one of the most important and effective ways to keep someone safe. This is when we restrict access to methods, or ways, that someone might harm themselves. This includes locking away firearms, knives, or prescription drugs. Means restriction reduces someone’s capability for suicide.

The second component of safety plans includes contact numbers. These numbers might be 911 for life-threatening emergencies, numbers for the local psychiatric emergency rooms, local or national crisis lines, and numbers for family or friends who may provide emotional support.

The third component of safety plans includes coping strategies based on how intense the person’s symptoms are. For example, if someone is having passive ideation and is generally feeling hopeless, but has no other signs or symptoms, we might encourage a coping strategy like engaging in a preferred activity. If, however, the signs and symptoms are more severe, we might then encourage contacting their therapist to set up a session. Think of this similarly to “If/Then” statements or symptom matching hierarchies. “If I feel this way, I should do this…” For this part of the safety plan, consider previous coping strategies and how well they worked. We want to encourage use of coping strategies that we know are effective for the client.

The fourth component of a safety plan should include identifying a person’s reasons for living. What are their hopes for the future? Do they have any goals? Things they would like to see? No reason to live is “too small”, but someone may need help to come up with what they’re looking forward to.

Finally, a safety plan should always include follow-up. How often should the person be checked in with? Typically, we want to check in with someone on a safety plan at least weekly if not more frequently. When we’re worried about someone being a danger to themselves, we want to involve whomever we believe will help. Surrounding someone with positive social support can alleviate many of the symptoms they’re experiencing.

Safety planning is therapeutic, not just a box to check, and can save someone’s life. When creating the safety plan, practice the coping strategies, call the crisis numbers to demonstrate how they work, and walk the person through how to use the safety plan. This should be an active, dynamic document that is frequently updated so it stays relevant.

There are also many interventions that can improve someone’s suffering and reduce suicidal ideation over time. These include cognitive behavior therapy, motivational interviewing, dialectical behavior therapy, and acceptance and commitment therapy. For further information about assessing suicide risk and safety planning, see Chu et al., 2015.

References:

Chu, C., Klein, K. M., Buchman, S. J. M., Hom, M. A., Hagan, C. R., & Joiner, T. E. (2015). Routinized assessment of suicide risk in clinical practice: An empirically informed update. Journal of Clinical Psychology, 71(12), 1186–1200. https://doi-org.dist.lib.usu.edu/10.1002/jclp.22210