Safety Planning in Emergency Settings

This article describes the Safety Planning Intervention (SPI), a brief intervention developed for use in emergency departments and other emergency settings. An SPI is a personalized action plan collaboratively developed by the patient and the clinician to help the patient recognize and take practical steps to cope with a suicidal crisis. The SPI was developed as an alternative to two interventions often used for suicidal patients whose condition is considered not serious enough for hospitalization:  (1) providing the patient with a referral to mental health services (which he or she may not use) and  (2) creating a “no suicide” contract (an intervention which has never been rigorously evaluated and shown effective).

The SPI is a detailed, written plan developed by the patient and clinician that outlines concrete steps a patient can take to recognize and respond to a suicidal crisis. The steps of an SPI include the following: (1) Recognizing the warning signs of an impending suicidal crisis. These warning signs can include thoughts, moods, and thinking styles as well as behaviors, such as spending more time alone or drinking more than usual. (2) Employing coping strategies that do not require assistance. These strategies could include reading, doing chores, or listening to music – whatever activity the patient feels might improve their mood and distract them from suicidal thoughts. This step can also strengthen the patient’s self-efficacy, which also can help protect a person from suicidal behavior. (3) Using social contacts and social settings to distract oneself from suicidal thoughts. During this step, the patient engages with other people to help combat the suicidal crisis, but does not tell others that he or she is in crisis. (4) Informing friends or family members about the suicidal crisis and seeking their help. The authors stress that these might be different people from those identified for Step 3, since a person who may help distract the patient (or improve the patient’s mood) may not be helpful when confronted with an explicit crisis. (5) Identifying and seeking help from mental health professionals or crisis services; and (6) Restricting access to lethal means.

The authors stress that the SPI should be as detailed and as concrete as possible. It should, for example, specify the activities, people, and social settings the patient should use as distractions;  the friends, family members, and mental health professionals (or agencies) to which a patient will turn in the event of a suicidal crisis; and precisely which lethal means present a danger to the patient and how they will be restricted (e.g. identifying which family members should be entrusted with keeping the patient’s medication in a secure place to prevent the possibility of an overdose).

The SPI has been identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention and is included in their Best Practices Registry for Suicide Prevention.

Note:

The September 13th issue of the Weekly Spark will include a Research Summary describing a brief safety planning intervention used in Department of Veterans Affairs emergency departments and urgent care settings.

Stanley, B., & Brown, G. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.