In this Making Sense of Suicide installment, I’ll be talking about safety planning. As usual, there is too much to cover in one post. First I’ll describe what safety planning is, provide a quick review of the research, and discuss key elements for ensuring a high quality safety plan. In a follow-up post, I’ll go over the individual sections, including my modifications, in more detail.

Purpose

The goal of a safety plan is to buy time. I always emphasize that a safety plan will not solve your problems. It will not make everything better. And…

It can break you out of a suicidal crisis long enough to buy you time to stay safe, and alive, to be able to benefit from care and ultimately no longer be suicidal.

The Research

Research has shown that safety planning is an acceptable and feasible treatment intervention with correlations to multiple improved outcomes (Ferguson, et. al., 2022), including reductions in suicidal behaviors (Nui, et. al., 2022). Another study, looking at use of suicide safety plans among Veterans post discharge from a psychiatric hospitalization for suicide, demonstrated that quality of the plan, and fidelity to the model, made a difference to outcomes (Kearns, et. al., 2024). This was particularly true when ensuring that items on the plan were specific and were congruent with the realities of the client’s situation.

For example, it was considered insufficient to put “relax” as an internal coping strategy and to list your spouse as a person to call when a warning sign for suicide was conflict with your spouse. They also found common errors in adequately addressing making the environment safe. Lastly, this study also indicated that clarity and specificity of warning signs had the most impact, because it supported building insight into the how and why of their suicidal thinking. Conversely, internal coping strategies were not as effective as anticipated. More on this in a bit.

The model used in this study was the Stanley-Brown Safety Planning Intervention. It is the format that you are most likely familiar with.

It includes six sections:

• Warning signs
• Internal coping strategies
• People/places that can offer distraction
• People you can call
• Professionals and emergency services
• Making the environment safe

Specific, Accessible, Feasible and Safe

We’ll get into the nuts and bolts of each section in a future blog. For now I want to talk about the framework of creating your safety plan. In other words, what’s needed for a high quality safety plan? You may recognize these categories from SMART goals; it’s not a perfect match, and it is my inspiration.

Specific

First and foremost, it has to be specific to the client. During a suicidal crisis, the frontal lobe is not working to capacity. The frontal lobe is what we use to make decisions, weigh options, plan for the future, and more. Note being able to access this way of thinking is what drives the tunnel vision (or cognitive constriction per Shneidman’s terminology) of suicide. As such, it is very difficult to think of what to do to cope in the moment when suicide is weighing you down. Thus we want to do all the thinking and planning upfront on our safety plan. If listening to music is one of your go-to forms of coping, great. Now get specific, what songs are you going to listen to? Maybe even make a playlist in advance. This way, when you get your plan out, you know exactly what to do and don’t have to make any decisions in the moment.

Accessible

Next is accessibility. For places to go, I like to frame it as a “treat yo self” situation. It’s hard to get motivated to get out of the door when you’re in a really dark place. It doesn’t seem worth it to get dressed and go to Starbucks because it’s on your safety plan and hopefully, maybe, it will pull you out of your funk. So I try to up the ante by making it a treat. What’s the craziest drink at Starbucks you can think of to try? Or what’s the drink you never let yourself get because it’s a billion calories. Now’s the time to get that drink. I’d rather you ruin your diet and stay alive. This approach is only accessible if the person can get to Starbucks and they have the funds to buy the pricey extra fancy beverage. Talk out the considerations, weigh the options, only include on the plan what the client can actually do. Transportation, finances, and time of day are the biggest barriers I encounter.

Feasible

Technically, there’s a lot of overlap between accessibility and feasibility. I differentiate them by thinking of feasibly as, will the client actually do it? Just because we identify listening to music and going to Starbucks as options, will they pick up their headphones or get in the car? Do they want to do it? Is there buy-in to these strategies? If not, they aren’t worth putting on the plan.

Safe

Lastly, and most importantly, is safety. The struggle with this is, it isn’t universal. For some, taking a drive up Mt. Lemmon (a mountain in Tucson known for its sharp curves and steep vistas) is a wonderful place they can go to connect to the beauty and wonder of nature. For others, it could be incredibly dangerous. If, for example, there is any temptation to ride their motorcycle at top speed or drive their car off the edge.

Safety also comes up a lot with firearms. In my experience working with Veterans, using firearms, whether cleaning them or going to the range, is a way of connecting with a sense of self, calm, accomplishment, and skill. And is working with firearms a safe thing to do during a suicidal crisis? 50% of suicide deaths in 2022 were by gunshot wound. As such, we’re usually talking about removing access to firearms as part of making the environment safe. So how do we navigate these opposing needs? We use validation and transparency and we prioritize safety.

We may have to navigate similar considerations when folks want to use alcohol or marijuana as a coping tool. To go on the safety plan, it has to be safe.

What’s Missing?

The research findings showing the limited benefit of internal coping strategies got me wondering… Do we need to beef up the identified coping strategies? Do folks have the skills needed at this time in their healing to maximally benefit? Is it an issue of getting up the “oomph” to use skills when in a dark pace?

Or, are we overly emphasizing the efforts of the individual? Safety plans are generally intended to be completed in order. You start with what you can do on your own, then you seek a change of scene, and then if that isn’t enough, you reach out to your support.

“Pull Yourself Up by Your Bootstraps”

This is a very Western/Colonial “pull yourself up by your bootstraps” approach. And maybe that’s part of the problem. Why don’t we start with seeking support from others? Why don’t we prioritize connecting with community? Per Joiner’s Interpersonal Theory of Suicide, we know that thwarted belongingness and perceived burdensomeness are key factors that create and perpetuate suicidal thinking. Shouldn’t we then be seeking to counter these beliefs as soon as possible? I recognize it’s not that simple. It may feel genuinely impossible to turn to others for support when you believe you are already asking too much, are too much, and they would be better off without you.

However, when we look outside individualistic norms, many other cultures would, and do, prioritize community connections. So it’s also possible that by not including community sooner in our safety plans, we are not adequately acknowledging the cultural needs and norms of our clients.

Community Connections

To relieve the effort of the individual and be more culturally adaptive, I propose adding a “community connections” section to safety planning. In my version, this is on the same “line” as internal coping strategies, to indicate that one is not better or more important than the other, nor does one need to come before the other. Rather, ideally we would be capturing elements for both sections, and the client can determine where they start.

Wrapping Up For Now

As promised, there is more to be discussed. Today covered the foundational ideas and principles for making a high quality safety plan. Next time I’ll go over the individual sections in more detail.

For Clinicians: Research has also shown that we don’t often get the training we need to feel confident making safety plans. If this has been the case for you, I hope this post is a helpful start. If you have had prior training, I hope this fills in some gaps and gives you more ideas for making safety plans that can really make a difference.

For Those Seeking Healing: If you think you might benefit from a safety plan, I hope this gives you some good ideas, and resources, for making one. And as I always say, these posts and resources are not therapy. If you are having thoughts of suicide, let someone know, ask for help, and if it’s a crisis, call 9-8-8 or go to your local emergency room.