Safety Planning

I don’t think I would ever really do anything, but…

I’ve been having urges to cut again…

I just don’t see the point anymore…

How do I rate my suicidal thoughts out of ten? Probably a seven or an eight…

People who come to see us often spend 167 hours each week shoving away these kinds of thoughts the way I try to shove one extra change of clothes into my suitcase before a trip. I might technically keep it all in there, but there’s no guarantee that it’s not going to come pouring out at some point when that poor zipper Just. Can’t Takeitanymore. Their one hour in therapy is often the only time they give voice to their darkest thoughts.

According to provisional data from the Centers for Disease Control, 47,646 Americans died by suicide in 2021. Suicide was the second-highest cause of death for people aged 10-34. For most of us, this statistic causes a deep and profound heartache and even anger. It also tends to stir fear—will I miss a signal from my client? Does she feel safe and understood by me? Does he know that I care enough to do anything it takes to stop this from happening? What can I do?

Dear Supervisee, there are things that you can and should do. (And if you’re not a supervisee but you’re reading this out of curiosity: thank you for joining us! Make your own safety plan. Read and leave comments below, especially if you have experience needing a safety plan and have feedback to share to help us improve.) First and foremost, make sure that you are skilled and trained in identifying and responding to risks. As a starter:

• Read/listen to this NPR interview with Thomas Joiner and then read his book, Why People Die by Suicide.

• If you’re practicing in Washington state, stay current with a required training approved by the Department of Health in this list of approved suicide prevention trainings. Mental health professionals are required to have at least six hours of training every six years according to the guidelines listed here.

• Get yourself to a training with role play and live practice. I recommend ASIST.

Assuming that clinical training is in place, come alongside your client and work together on making a plan. In that session. Before the client leaves the office. Here are some of the things to address in a safety plan/crisis plan/wellness plan/Terrible-Horrible-No-Good-Very-Bad-Day plan:

1. Identify the Crisis Situation.

For many, this is suicide. For others, it may be cutting, running away, spending a depressed week in bed, making risky decisions during mania/hypomania, etc. It may be helpful to list the dates that these things have happened in the past.

2. Vulnerabilities

What makes your client more vulnerable to harmful decisions or behaviors? What circumstances are more likely to cause things to take a turn for the worst? Help your client know and understand the risk factors so that they can intervene earlier. This list can be made either by naming the vulnerabilities (i.e. intoxication) or more positively by articulating a crisis prevention plan (go to meetings and maintain sobriety).

3. Warning Signs

When you hear John Williams’ glorious theme from the movie Jaws, your brain knows that there’s a shark in the water. Nuh nuh. Nuh nuh. Nuhnuhnuhnuhnuhnuhnuhnuh! What are the warning signs, the Jaws music cues, that things might be getting rough for your client?

4. Coping Strategies

This is the heart and soul of the plan. What can the individual do to feel better? Ideally, list things to try in order.

5. Look for Things That Make It Worse

Bad situations can get worse. Make sure you know what might make it harder for your client to recover from a crisis state. Maybe he hates to be told everything happens for a reason. Maybe eating comfort food will lead to self-loathing.

6. The One Big Thing

If there is one thing worth living for or staying healthy for, name it. Don’t underestimate the power of pets.

7. List Supports and Resources

Natural supports are best. Professional supports should include the local crisis number, national numbers, and any numbers specific to the client’s specific challenge (AA sponsor, gambling hotline, etc.).

Sample Plan (may be written in a first-person voice; this is a very basic plan for illustrative purposes only):

Risks

Muffy has recurrent depression. When it gets bad, she contemplates suicide and cuts on her left forearm.

Vulnerabilities

Muffy is more prone to cutting and suicidal thoughts in the dark days of winter. Spending too much time on social media, not getting enough sleep and exercise, drinking alcohol, and spending too much time with her parents tends to make things worse for her. She is prescribed medications for depression and does best when she takes them regularly.

Warning Signs

Muffy is highly conscientious and well-connected. Missing therapy appointments, calling out sick from work, or getting behind on her bills would be signs that she is not doing well. Withdrawing from her two closest friends, Daisy and Rose, is also a sign. She gets cynical and tends to swear more when she is really depressed. Her dog, Fluffy, is her life. Any attempt to rehome Fluffy is a red flag.

Coping Strategies

In the wintertime or other times that are starting to get hard for Muffy:

· Sit by a light box for 30 minutes in the morning

· Listen to the “Here Comes the Sun” playlist when driving to work

· Schedule a weekend getaway with Rose and Daisy

· Make sure to take medications

· Get outside and go for a walk or go to the gym 3-5 days a week

· Increase therapy from biweekly to weekly

· Start a project (knit something, paint something, build something, bake something)

· Ask Daisy to keep your sharps for a while and check in on cutting urges, checking forearms

When thoughts of suicide or self-injury are intense:

· Call Rose and practice 5-4-3-2-1 and breathing exercises with her, ask her to pray

· Stay with Rose or Daisy if needed

· Ask Rose or Daisy to check in daily (or more frequently) on cutting urges

· Write out your mantra and repeat it frequently, use a dry-erase pen to write it on mirrors

· Make a list of 50 gratitudes

· Make a list of people who love you and whom you love

· Listen to the “Stayin’ Alive” playlist

· Hold an ice cube until it melts

· Take Fluffy for a run or walk

· Take a hot bath and drink tea

· Go to urgent care if medications are an issue

· Call the crisis line at 1-800-xxx-xxxx if it feels hard

· Call 911 if it feels impossible

Things That Make It Worse

· Muffy hates to be told, “This too shall pass.”

· Her parents increase her feelings of guilt and shame, so it’s best to minimize contact during depressive times

· When Muffy drinks, she makes poor choices that make her feel bad about herself when she sobers up, so it’s best to avoid alcohol in times of depression.

The One Big Thing

Muffy has always been able to stay safe when she thinks about what would happen to Fluffy if she wasn’t there.

Supports

Rose Posy, friend, 555-555-5555

Daisy Day, friend 555-555-55556

Pastor Lovingheart, pastor, 555-555-5557

Ned Niceguy, neighbor, 555-555-5558

Crisis line: 1-800-xxx-xxxx

911