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Recognizing that, despite best efforts, some patients will not seek treatment following an emergency evaluation for a suicidal crisis, and further recognizing that there is an inevitable lag between an ED evaluation and outpatient mental health appointments, we suggest that the ED visit or other acute care setting may serve as a valuable opportunity to conduct a brief intervention that may reduce further suicidal behavior. Furthermore, given that suicidal crises may be relatively short-lived and have an ebb and flow pattern, an intervention that assists patients in coping with such crises may be particularly useful, even if the intervention is only used for a brief period of time until the crisis diminishes. For example, the effectiveness of means restriction is largely based on the fact that suicidal thoughts tend to subside over time and that making it more difficult for patients to act on these thoughts would be a helpful preventive measure (Daigle, 2005). Similarly, if patients are given tools that enable them to resist or decrease suicidal urges for brief periods of time, then the risk for suicide is likely to decrease.

Similar approaches to addressing acute suicidal crises have been developed by others, predominantly in the context of ongoing outpatient or inpatient care, but not as stand-alone interventions. For example, Rudd and his colleagues developed the crisis response plan that emphasizes what patients will do during a suicidal crisis (Rudd, Joiner, & Rajab, 2001). The crisis response plan is part of a cognitive behavioral therapy intervention that is aimed at reducing suicide risk. It involves helping patients to identify what triggers the crisis, use skills to tolerate distress or regulate emotions, and, should the crisis not resolve, access emergency care. Specifically, the crisis response plan is a series of therapeutic interventions that ensures the safety of the patient by removing access to lethal means; initiating self-monitoring of the suicidal thoughts, feelings, and behaviors; targeting symptoms that are most likely to interrupt day-to-day functioning; targeting hopelessness and sense of isolation, reinforcing the commitment to treatment and solidifying the therapeutic relationship. Similarly, David Jobes uses a safety plan approach in the context of his approach, Collaborative Assessment and Management of Suicidality (CAMS), a psychotherapeutic approach for managing suicidal patients, in both outpatient and inpatient settings (Jobes, 2006). The CAMS safety plan focuses on whom to call during a suicidal crisis and cleansing the environment of means to commit suicide.

Both safety plans and crisis response plans have been used as therapeutic strategies in the context of other short-term, empirically supported treatments that have been found to reduce suicide risk, such as cognitive therapy (Brown et al., 2005; Wenzel, Brown, & Beck, 2009) or cognitive behavior therapy for suicide prevention (CBT-SP; Stanley et al., 2009). However, to our knowledge, the use of a safety planning intervention as a single-session, standalone intervention for emergency care settings has not been explicitly described. Yet other novel targeted interventions have been proposed. Rotheram-Borus et al. (2000) tested an ED intervention for suicidal adolescents that involved psychoeducation about the importance of treatment in suicidal teens for both the ED staff and the patients. Kruesi et al. (1999) and McManus et al. (1997) developed psychoeducation programs that stressed the need to restrict access to means when there was a suicidal adolescent in the home. Sneed, Balestri, and Belfi (2003) adapted dialectical behavior therapy (DBT) skills in a single-session format for the ED. Despite these proposed interventions, the standard of “assess and refer” approach to care remains.

While other efforts at safety planning have been described in the literature, the SPI is unique in that it is a systematic and comprehensive approach to maintaining safety in suicidal patients. Prior efforts have primarily focused on a single aspect of safety (e.g., means restriction or emergency contacts). Furthermore, the explicit focus on utilizing internal coping and distracting strategies as a step in an emergency plan to deal with suicidal urges is not typically an aspect of most safety plan efforts even though it is an aspect of therapies targeting suicidal feelings (e.g., CT and DBT).

Safety Planning Vs. No-Suicide Contract

Another type of brief intervention that is pro-vided for suicidal patients is a “no-suicide contract.” This intervention is a written or verbal agreement between the clinician and patient re-questing that the patient refrain from engaging in suicide behavior. The SPI is quite different from a no-suicide contract intervention given that the no-suicide contract does not necessarily provide detailed information about how patients should respond if they become suicidal.

A no-suicide contract usually takes the form of asking patients to promise not to kill themselves and to contact professionals during times of crisis (Stanford, Goetz, & Bloom, 1994). In contrast, the safety plan is not presented to patients as a no-suicide contract. Despite the anecdotal observation that no-suicide contracts may help to lower clinician anxiety regarding potential suicide risk, there is no empirical evidence to support the effectiveness of no-suicide contracts for preventing suicidal behavior (Kelly & Knudson, 2000; Reid, 1998; Shaffer & Pfeffer, 2001; Stanford et al., 1994). To our knowledge, there are no randomized controlled trials (RCTs) that have examined the efficacy of no-suicide contracts for preventing suicide or suicide attempts. There have been a few studies that have examined the clinical utility of no-suicide contracts, but findings have been inconsistent (Drew, 2001; Jones, O’Brien, & McMahon, 1993; Kroll, 2000; Mishara & Daigle, 1997). The methodological problems with these studies and the lack of RCTs have led to the conclusion that there is no empirical support for the efficacy of this intervention. (see Rudd, Mandrusiak, & Joiner, 2006). Clinical guidelines also caution against using no-suicide contracts as a way to coerce patients not to kill themselves, as it may obscure the determination of the patients’ actual suicidal risk (Rudd et al., 2006; Shaffer & Pfeffer, 2001). For example, patients may withhold information about their desire to kill themselves for fear that they will disappoint their treating clinicians by violating the contract. Rather, the SPI is presented as a strategy to illustrate how to prevent a future suicide attempt, and identifies coping and help-seeking skills for use during times of crisis.

Intervention Description

The SPI, a very brief intervention that takes ap-proximately 20 to 45 minutes to complete, pro-vides patients with a prioritized and specific set of coping strategies and sources of support that can be used should suicidal thoughts re-emerge. The intent of the safety plan is to help individuals lower their imminent risk for suicidal behaviour by consulting a predetermined set of potential coping strategies and a list of individuals or agencies they may contact; it is a therapeutic technique that provides patients with more than just a referral at the completion of the suicide risk assessment during an emergency evaluation. By following a predetermined set of internal coping strategies, social support activities, and help-seeking behaviors, patients have the opportunity to evaluate those strategies that are most effective. While we recommend that the interventions be followed in a stepwise manner, it is important to note that if a patient feels at imminent risk and unable to stay safe even for a brief time, then the patient should immediately go to an emergency setting. Furthermore, some patients may feel that they cannot or do not wish to use one of the steps in the safety plan. In this instance, they should not feel that they must do so as the intent of the safety plan is to be helpful and not a source of additional stress or burden.

The SPI is best developed with the patient following a comprehensive suicide risk assessment (cf. American Psychiatric Association, 2003). During the risk assessment, the clinician should obtain an accurate account of the events that transpired before, during, and after the recent suicidal crisis. Patients typically are asked to describe the suicidal crisis, including the precipitating events and their reactions to these events. This review of the crisis facilitates the identification of warning signs to be included in the safety plan and helps to build rapport. Consistent with an approach described by Jobes (2006), a collaborative stance is most effective for dev-eloping the safety plan. The basic components of the safety plan include (a) recognizing warning signs of an impending suicidal crisis; (b) employing internal coping strategies; (c) utilizing social contacts as a means of distraction from suicidal thoughts; (d) contacting family members or friends who may help to resolve the crisis; (e) contacting mental health professionals or agencies; and (f) reducing the potential use of lethal means. The first five components are employed when suicidal thoughts and other warning signs emerge. Reducing access to means is discussed after the rest of the safety plan has been completed, often with the aid of a family member or friend, for an agreed upon period of time. Each of these steps is reviewed in greater detail below.

Recognition of Warning Signs

The first step in developing the safety plan in-volves the recognition of the signs that immediately precede a suicidal crisis. These warning signs include personal situations, thoughts, images, thinking styles, moods, or behaviors. One of the most effective ways of averting a suicidal crisis is to address the problem before it fully emerges. Examples of warning signs include feeling irritable, depressed, hopeless, or having thoughts such as, “I cannot take it anymore.” Similarly, patients can identify problematic behaviors that are typically associated with suicidality, such as spending increased time alone, avoiding interactions, or drinking more than usual. Generally, more specifically described warning signs will cue the patient to use the safety plan, than warning signs that are more vaguely described.

Internal Coping Strategies

As a therapeutic strategy, it is useful to have patients attempt to cope on their own with their suicidal thoughts, even if it is just for a brief time. In this step, patients are asked to identify what they can do, without the assistance of another person, should they become suicidal again. Prioritizing internal strategies as a first-level technique is important because internal strategies enhance patients’ self-efficacy and can help to create a sense that suicidal urges can be mastered. This, in turn, may help them feel less vulnerable and less at the mercy of their suicidal thoughts. Such activities function as a way for patients to distract themselves from the crisis and prevent suicide ideation from escalating. This technique is similar to those described in DBT (Linehan, 1993), a cognitive behavioural therapy for suicidal individuals with borderline personality disorder that instructs patients to employ distraction techniques when they are experiencing intense urges to make a suicide attempt. Examples of these coping strategies include going for a walk, listening to inspirational music, going online, taking a shower, playing with a pet, exercising, engaging in a hobby, reading, or doing chores. Activities that serve as “strong” distractions vary from person to person and, therefore, the patient should be an active participant in identifying these activities. Engaging in such activities may also help patients experience some pleasure, sense of mastery, or facilitate a sense of meaning in their lives. However, the primary aim of identifying and doing such activities is to serve as a distraction from the crisis.

After the internal coping strategies have been generated, the clinician may use a collaborative, problem-solving approach to ensure that potential roadblocks to using these strategies are addressed and/or that alternative coping strategies are identified. If patients still remain unconvinced that they can apply the particular strategy during a crisis, other strategies should be developed. Clinicians should help patients to identify a few of these strategies that they would use in order of priority; the strategies that are easiest to do or most likely to be effective may be listed at the top of the list.

Socialization Strategies for Distraction and Support

If the internal coping strategies are ineffective and do not reduce suicidal ideation, patients can utilize socialization strategies of two types: socializing with other people in their natural social environment who may help to distract them-selves from their suicidal thoughts and urges or visiting healthy social settings. In this step, patients may identify individuals, such as friends or family members, or settings where socializing occurs naturally. Examples of the latter include coffee shops, places of worship, and Alcoholics Anonymous (AA) meetings. These settings de-pend, to a certain extent, on local customs, but patients should be encouraged to exclude environments in which alcohol or other substances may be present. In this step, patients should be advised to identify social settings or individuals who are good “distractors” from their own thoughts and worries. Socializing with friends or family members, without explicitly revealing their suicidal state, may assist in distracting patients from their problems and their suicidal thoughts; this strategy is not intended as a means of seeking specific help with the suicidal crisis. A suicidal crisis may also be alleviated if patients feel more connected with other people or feel a sense of belongingness.

Social Contacts for Assistance in Resolving Suicidal Crises

If the internal coping strategies or social contacts used for purposes of distraction offer little benefit to alleviating the crisis, patients may choose to inform family members or friends that they are experiencing a suicidal crisis. This step is distinguished from the previous one in that patients explicitly reveal to others that they are in crisis and need support and assistance in coping with the crisis.

Given the complexity of deciding if patients should or should not disclose to others that they are thinking about suicide, the clinician and patient should work collaboratively to formulate an optimal plan. This may include weighing the pros and cons of disclosing their suicidal thoughts or behavior to a person who may offer support. Thus, for this step, someone who may help to distract patients from their suicidal urges may not be the best person for assisting patients with a suicidal crisis when suicidal thoughts are dis-closed. Patients should be asked about the likelihood that they would contact these individuals and whether these individuals would be helpful or could possibly exacerbate the crisis. If possible, someone close to the patient with whom the safety plan can be shared should be identified and should be named on the plan. It should be noted that sometimes patients are unable to identify someone because they may not feel comfortable sharing the plan with family or friends.

Professional and Agency Contacts to Help Resolve Suicidal Crises

This component of the plan consists of identifying and seeking help from professionals or other clinicians who could assist patients during a crisis. The clinicians’ names and the corresponding telephone numbers and/or locations are listed on the plan and may be prioritized. Patients are instructed to contact a professional or agency if the previous strategies (i.e., coping strategies, contacting friends or family members) are not effective for resolving the crisis. If patients are actively engaged in mental health treatment, the safety plan may include contact information for this provider. However, the safety plan should also include other professionals who may be reached, especially during non-business hours. Additionally, contact information for a local 24-hour emergency treatment facility should be listed as well as other local or national support services that handle emergency calls, such as the national Suicide Prevention Lifeline: 800-273- 8255 (TALK).

The safety plan emphasizes the accessibility of appropriate professional help during a crisis and, when necessary, indicates how these services may be obtained. The clinician should discuss the patients’ expectations when they contact professionals and agencies for assistance and dis-cuss any roadblocks or challenges in doing so. Patients may be reluctant, at times, to contact professionals and disclose their suicidality for fear of being hospitalized or being rescued using a method that is not acceptable to them. As with the other components of the plan, the clinician should discuss any concerns or other obstacles that may hinder patients from contacting a professional or agency. Only those professionals whom patients are willing to contact during a time of crisis should be included on the safety plan.

Means Restriction

The risk for suicide is amplified when patients report a specific plan to kill themselves that involves a readily available lethal method (Joiner et al., 2003). Even if no specific plan is identified by patients, a key component of the safety plan intervention involves eliminating or limiting access to any potential lethal means in the environment. This may include safely storing and dispensing of medication, implementing firearm safety procedures, or restricting access to knives or other lethal means. In developing a safety plan, means restriction is addressed after patients have identified ways of coping with suicidal feelings because, if they see that there are other options to acting on their suicidal urges than committing suicide, they may be more likely to engage in a discussion about removing or restricting access to means. Depending on the lethality of the method, the manner in which the method is removed or restricted will vary. Generally, clinicians should ask patients which means they would consider using during a suicidal crisis and collaboratively identify ways to secure or limit access to these means. Clinicians should routinely ask whether patients have access to firearms, regardless of whether it is considered a “method of choice,” and make arrangements for securing them. For methods with lower lethality (such as drugs or medication with a low level of toxicity), clinicians may ask patients to remove or restrict their access to these methods themselves when they are not experiencing a crisis. For example, if patients are considering overdosing, having them ask a trusted family member to store the medication in a secure place might be a useful strategy.

The urgency and importance of restricting access to a lethal method is more pronounced for highly lethal methods. For methods of high lethality, such as a firearm, asking patients to temporarily limit their access to such means themselves by giving it to a family member or other responsible person may be problematic, as patients’ risk for suicide may increase further as a result of direct contact with the highly lethal method. Instead, an optimal plan would be to restrict patients’ access to a highly lethal method by having it safely stored by a designated, responsible person – usually a family member or close friend, or even the police (Simon, 2007). Patients who are unwilling to remove their access to a firearm may be willing to limit their access to the firearm by having a critical part of the firearm removed or by using a gunlock and having the gunlock key removed. Clinicians should also be aware that restricting access to one lethal method does not guarantee patients’ safety because they may decide to use another one. The specific behaviors necessary to make the patients’ environment safer should be noted on the safety plan and the length of time (e.g., 1 month, 2 weeks) that this restriction should be in place can be noted.

It is important to note that the SPI should be administered in a collaborative manner with patients. The coping strategies, external supports and triggers to suicidal urges are generated together by the clinician and patient and the patient’s own words are used in the written document. The collaborative nature of this intervention is essential to developing an effective safety plan. A clinician-generated list of coping strategies is unlikely to be helpful to a patient in the absence of knowing what strategies are most compelling for the individual. Similarly, “typical” triggers to suicidal feelings are not useful if they do not have personal relevance. On the other hand, the patient is not left alone to struggle with identifying his or her triggers and best means for coping. Instead, clinicians can offer suggestions and inquire in a supportive manner to help the patient complete the intervention.

After the SPI is complete, clinicians should assess the patient’s reactions to it and the likelihood he or she will use the safety plan. One strategy for increasing patient motivation to use the safety plan during a crisis is to ask the patient to identify the most helpful aspects of the plan. If the patient reports or the clinician determines that there is reluctance or ambivalence to use the plan, then the clinician should collaborate with the patient to identify and problem solve potential obstacles and difficulties to using the safety plan. Role playing the use of the SPI may be helpful if clinicians have sufficient time available and the patient is willing to engage in this exercise. Once a patient indicates his or her willingness to use the safety plan during a crisis, then the original document is given to the patient to take with him or her and a copy is kept in the medical record. The clinician also discusses where the patient will keep the safety plan and how it will be retrieved during a crisis. This may include making multiple copies of the plan to keep in various locations or changing the size or format of the plan so that it could be stored in a wallet or electronic device that is easily accessible. In order to increase the likelihood that the safety plan would be used, the clinician may consider conducting a role-play during which the patient would describe a suicidal crisis and then would provide a detailed description of locating the safety plan and following each of the steps listed on the it.

Clinicians with a wide range of backgrounds (e.g., nurses, psychologists, primary care physicians, psychiatrists, social workers) can be train-ed to implement the SPI. The typical training includes: (a) reading the safety plan manual (Stan-ley & Brown, 2008a), reviewing the brief instructions (Stanley & Brown, 2008b) and the safety planning form; (b) attending a training in which the intervention, its rationale and evidence base are described; and (c) conducting role-plays to practice implementing the intervention.

The SPI was developed to be used in settings where emergency services or acute care services are provided, such as EDs, trauma units, crisis hot lines, or medical emergency response units. In addition, the SPI may be used as a part of ongoing mental health treatment in outpatient settings for individuals at risk for suicidal behavior. In this context, safety plans may be revised over time as new coping skills are learned, as new risk factors and precipitants are identify-ed or as the social network changes. We propose that the SPI may be useful in other settings where psychiatric, medical, or psychosocial ser-vices are provided, such as inpatient psychiatric settings, military or correctional settings. For these settings, the SPI has to be adapted to ac-knowledge the limited availability of coping strategies and people who can be enlisted. Institutional staff may require specialized training for determining when patients should be encouraged or coached to follow their safety plan and when a higher level of observation or other external precaution should be implemented.

It is recognized that the application of the SPI will vary depending on the population as well. For example, when developing safety plans with adolescents, it may be important to identify key adults who may become part of the plan. Adolescents are able to aid in determining which family members or other responsible adults are more likely to have a calming and positive influence. Some family members, particularly those with whom the adolescents have frequent conflicts, may not be good candidates to enlist as contacts on the safety plan. Family members can also be coached to help the adolescent use the safety plan. In addition, special care must be when helping the adolescent identify individuals other than family members who may offer support and distraction from the suicidal crisis.

Patients evaluated for suicide risk in EDs and other emergency settings for whom hospitalization is no clinically indicated are often offered the same disposition as nonsuicidal outpatients (Schulberg, Bruce, Lee, Williams, & Dietrich, 2004; Spirito et al., 2002). The management and treatment of suicidal patients in outpatient set-tings can be burdensome and anxiety-provoking for clinicians and may diminish their motivation to treat these patients. Although protocols have been developed for managing suicidal crises in outpatient settings (Jobes, 2006; Rudd, 2006, Stanley et al., 2009; Wenzel et al., 2009), these strategies have been developed as part of on-going and longer-term treatment. Brief crisis interventions, such as safety planning, may be especially useful when the opportunity for longer-term care is limited or, alternatively, as an adjunct to treatment.

The SPI is a promising intervention to mitigate risk of suicide when evaluating and treating patients who are at increased risk for suicide. It can serve as a valuable complement to risk assessment, particularly for those patients who do not require psychiatric hospitalization. The SPI has several advantages. It is both easy to learn and easy to utilize. Staff can be trained readily, and in our clinical experience, the safety plan intervention is easier to learn than conducting a comprehensive risk assessment. Furthermore, it may be incorporated into the treatment of suicidal individuals, regardless of the clinician’s theoretical perspective.

This intervention has been used clinically by the authors (e.g., Stanley et al., 2009) and has been used as part of other evidence-based psycho-therapy interventions in clinical trial research. Its efficacy as a stand-alone intervention is currently being evaluated by us in an urban ED and nationally in a Department of Veteran Affairs clinical demonstration project. We describe only one format or version of a safety plan and recognize that other formats may be useful as well.

Safety Plan

1. Warning signs
   • Suicidal thoughts and feeling worthless and hopeless
   • Urges to drink
   • Intense arguing with girlfriend
2. Internal coping strategies – Things I can do to take my mind off my problems without contacting another person
   • Play the guitar
   • Watch sports on television
   • Work out
3. People and social settings that can help distract me
   • AA Meeting
   • Joe Smith (cousin)
   • Local Coffee Shop
4. People I will ask for help
   • Name: Mother Phone: 333-8666
   • Name: AA Sponsor (Frank) Phone: 333-7215
5. Professionals or services I can contact during a crisis
   • Clinician Name: Dr John Jones Phone: 333-7000
   • Clinician Pager or Emergency Contact #: 555-822-9999
   • Local Hospital ED: City Hospital Centre
   • Local Hospital ED Address: 222 Main St
   • Local Hospital ED Phone: 333-9000
   • Suicide Prevention Lifeline Phone: 1-800-273-TALK
6. Making the environment safe
   • Keep only a small amount of pills in home
   • Don’t keep alcohol in home