In a previous post, I talked about the rationale and considerations for making a safety plan. Then I went through each of the sections of a safety plan. This included warning signs and coping strategies you can do on your own, and coping strategies through community connections. It also reviewed places you can go, and people you can call. Today, I’ll wrap up this series by reviewing the final sections: providers/emergency resources and making the environment safe.

Providers and Emergency Resources

If, having gone through the prior sections of the plan, suicidal thoughts and urges have not abated, then we want to consider elevating care. This can mean contacting your therapist, medication provider, case manager, care coordinator, or a clinic or insurance-based nursing line. Which resources are available, for both clinicians and utilizers, will be system-dependent. For example, does your community-based clinic offer a 24-hour nursing line? For clinicians who work in private practice, I strongly encourage having clear expectations for between-session and emergency contact that is established at the start of treatment.

If a client’s providers are not available or do not provide such services, then we turn to warm lines. The specific phone numbers and offerings may vary by state and county. They are not often staffed 24/7 or on holidays. However, the national mental health emergency number, 9-8-8, is available 24/7.

Thus, in this section, you write out the names, phone numbers, and time frame availabilities of the providers and community resources that can be contacted for additional support when coping with suicidal thinking.

I end this section by including “go to your local emergency room.” As I discussed in a past post, there can be a lot of fear and anxiety about going to the hospital. And there is a time and place for hospitalization, particularly if you have reached the limits of what you can do to cope on your own.

Making the Environment Safe

The final section of a safety plan is making the environment safe. It documents what changes can be made in the home or workplace to reduce access to lethal means. As I’ve previously reviewed, safety planning is about buying time. The additional step of having to unlock a firearm versus simply getting it from the nightstand can make all the difference. Research demonstrates that establishing barriers between yourself and lethal means can be sufficient for thwarting suicidal thoughts from turning into suicidal actions.

Firearms

I used firearms as an example intentionally. According the the CDC, 50% of the deaths by suicide in 2022 were by gunshot wound. Even if a client hasn’t labeled firearms as their identified method, I always talk about it in this section. If they don’t have a gun in the house, I notate “continue to keep firearms out of the home” on their plan. This is dually valuable in affirming the importance of reducing risk by this means, and in having clear documentation that firearms have been discussed.

Risk/Rescue Factors

Lethality of suicidal behaviors and attempts are measured by the risk versus rescue factors. Risk factors include using a method with a high probability of resulting in death and engaging in the behavior in isolation. Rescue factors are the reverse, low risk of medical damage and death with opportunities for intervention by the self or others.

What makes firearms so dangerous is that they are highly medically lethal and there is no opportunity, once the trigger has been pulled, for intervention. Thus another layer of justification and rationale for always talking about firearms in your safety plans.

Assessment

If there are firearms in the home, I assess their relationship to firearms. First and foremost, by assessing whether it is a method they have considered for suicide. If the answer is no, I would ask if there are any circumstances they can imagine that would change their mind? Do they have a history of suicidal behaviors involving firearms? (Ideally, this would have already been addressed, and it can’t hurt to double-check.) Do they struggle with impulsivity? Is there a chance that even if they are saying now that they wouldn’t use a gun, in the heat of the moment, with a pattern of impulsivity, they might turn to their gun? Where are the guns currently stored? Are they loaded?

Safety

We talk about increasing safety by reducing accessibility. The options, from most ideal to least, include:

• Removing the firearms from the home (and keeping with a trusted family member or friend for the duration of suicidality);
• Storing guns and ammo in a separate locked safe with a loved one responsible for the key;
• Using a gun lock.

Not everyone is going to be amenable to engaging in this type of safety planning. And it is not my job to take away anyone’s guns. Or to challenge, or impede, their ability to do what they feel is necessary to keep themselves safe. This is particularly true for folx who live in areas with a higher likelihood of violence and/or are survivors of violence. As clinicians, we can only do our best to validate the valid, provide education, be encouraging, and engage in creative problem-solving.

Creative Problem-Solving

Creative problem-solving can look like storing all but one firearm. Then maybe tying a ribbon around the gun with a note or symbol to cue the use of safety planning. Anything to prompt a moment to pause, and hopefully connect with an alternative for coping, a reason for living, or a protective factor.

As an aside, one thing safety plans lack is listing out reasons for living and protective factors. This is an element of the Suicide Status Form that I really appreciate. Maybe in the next round of edits on my version of a safety plan, I will add these components. And yes, protective factors and reasons for living can be different.

Other Methods

If I know the client has an identified method, we will start there and do a check-in on firearms later. And I hope I was clear about why I opted to start with addressing firearms.

It is imperative to assess if the client has identified a method. And then address that method here. Even if the immediate answer is no, it is ok to probe to see if they have considered various methods at all. Methods vary by geographic region (nationally and internationally). After firearms, the most common methods include strangulation and poisoning either by pills or household toxins. As with guns, the best way to make the environment safe is by removing whatever can be taken out of the home or workplace (if they are at risk of engaging in suicidal behaviors at work). Again, you might need to get creative. It’s not feasible to get rid of every knife in the house or not have access to needed medications. And, whatever solutions you come up with are not about fragilizing or infantilizing the client. It is about taking suicidal risk seriously and being practical and proactive.

Medications

For folx who struggle with taking their medications safely and/or have identified overdose as a possible method, I recommend using a seven-day medication organizer. I suggest setting it up at the beginning of the week and storing the remainder of the prescription(s) in a locked container, or under the care of a loved one in the home.

Hospitalization

What do you do if your client isn’t willing or able to make the environment safe? One of the hardest parts of being a therapist is recognizing and tolerating that, at the end of the day, we cannot make our clients do anything. Nor is it our job to. As I said earlier, we can validate, educate, encourage, and get creative.

And we do have our own moral and ethical obligations to promote safety to the best of our abilities. If your clinical assessment indicates that the client is at high risk for imminent death by suicide and they are unwilling to engage in safety planning, including removing access to their identified method, then you likely need to be talking about hospitalization. Share your concerns and your ethical obligations clearly and with kindness. Explain your stance and see if there is any collaborative decision-making and (again) creative problem-solving to be had, including potentially mutually agreeing to hospitalization.

Concluding Thoughts…

Making the Environment Safe can be the heaviest part of suicide safety planning. I highly encourage engaging in these discussions in a warm, open, and direct manner. Dancing around these topics will not give you the data you need, nor will it help your client. And avoid being demanding or coercive. Collaboration is the name of the game.

For Clinicians: I hope this post, and the safety planning series as a whole, has given you more confidence in your ability to make thorough, feasible, and collaborative safety plans.

For Those Seeking Healing: I hope you don’t ever need a safety plan, and if you do, I hope this series has given you a better understanding of the hows and whys of including safety plans in your care. As always, these posts are not therapy; please call 9-8-8 if you are having a mental health crisis.