Safety Planning is an evidence-based strategy for preventing individuals from acting on suicidal thoughts[1]. Having a safety plan handy when suicidal thoughts intrude one’s headspace can provide the individual with access to previously identified actions and activities that have been effective in the past. The Safety Planning instrument has six key components:

1. Knowing the warning signs that lead to/ have led to suicidal thoughts—Help your patient identify symptoms and/or factors that have historically led to/been followed by suicidal thoughts. This may include internal factors such as unshakeable negative thoughts, periods of depression, feelings of hopelessness, intrusive images from past traumas, and/or overwhelming desire to isolate or escape, as well as external factors such as loss of a relationship or employment.

2. Identifying internal coping strategies that have historically helped the patient take their mind off suicidal thoughts—this may include a list of tasks and/or activities that have historically helped the patient distract her/himself, at least temporarily, from the suicidal thought(s). Ideally these would be activities that can be individually accomplished, such as going for a walk, meditating, exercising, journaling, etc., such that the patient can achieve them on their own.

3. Identifying the people and social settings that provide distraction from the suicidal thoughts—these may include a list of people whom the patient has historically benefited from reaching out to, as well as places that have provided comfort (such as places of worship or recreational clubs).

4. Listing the people in one’s life whom the patient can ask for help—this can include family members, friends, trusted coworkers, neighbors etc.

5. Listing the health care professionals the patient is engaged with whom they can ask for help—this can include the patient’s therapist or psychiatrist (if the patient is connected to mental health care), or their care manager (if the patient is enrolled in care management services), and can also include the primary care physician.

6. Identifying the actions one can take to make their environment safe—this can include removing or placing distance between the patient and the means for suicide they are considering/has considered or used in the past. For example, a patient who considers taking their life using a firearm could place the firearm in a lock box and store the key elsewhere in the home, or even better, with a trusted friend or family member. Ideally, the firearm would be stored with its component parts separated, if possible, and the ammunition would be stored in a different area of the home or at another location. Such an approach necessitates time and effort in making the lethal means accessible and usable, and creates obstacles for the patient to proceed with the plan for suicide.

When a patient’s choice of means involves common household objects such as sharp objects (kitchen knives, box cutters etc.), or prescription medications such as opioids or benzodiazepines, the plan for making the environment safe may require more forethought to consider the practical need for access to these objects (for the individual as well as cohabiting family members), and involve storing the medications in locations that require effort to reach (such as high shelves, in a locked compartment), or with a trusted friend or family member who can help intervene.

The six steps of the Safety Planning instrument are presented visually below:

In addition to the core components of a Safety Plan, it is helpful to carefully consider the following process elements of establishing a Safety Plan:

1. Build the plan collaboratively with the patient—they are more likely to adopt a Safety Plan that they developed and it is crucial that the patient follows this plan in moments of crisis. Even a sound plan whose details are proposed by the clinician may not ring true to the patient as applicable to them. Clinicians may recommend establishing a Safety Plan, and may even offer suggestions based on prior experiences of success with other patients; however, these are most appropriate when offered as suggestions, and confirmed as applicable and relevant to the patient. For example, a clinician may ask: “What are some strategies for coping with the thought to kill yourself that have worked for you in the past?” If the patient cannot identify any, the provider may say, “Sometimes people find that going outside for a walk or run, or talking to a friend helps them, do you think that may be something that would help you?”

2. A Safety Plan is not a contract. It is important to understand that keeping themselves safe is a choice the patient can make. By completing and following a Safety Plan, the patient is agreeing to collaborate with the clinician on ways to keep themselves safe. As such, there may be moments when the Safety Plan was not as helpful as expected in the moment, and/or the patient does not even attempt to follow the Safety Plan in a moment when they are overwhelmed with suicidal thoughts. How these moments, possibly received by both the patient and the clinician as ‘failures,’ are discussed are important to the Safety Planning strategy remaining useful to the patient. When discussing these moments, the clinician must maintain a non-judgmental, open, and exploratory stance. Rather than saying, “We agreed that you would call your mom, go for a walk, and then call me! Why didn’t you do that?,” the provider may say, “It sounds like while you had considered a few possible steps you could take when the thoughts came up again, it was difficult to take those steps to keep yourself safe in practice. Help me understand what got in the way of each one.”  Note that this approach, even when executed well by the clinician, can be quite difficult for the clinician internally as well as interpersonally. It is vital that clinicians take the time and space to process these moments with their own supervisors, particularly if they identify feelings of frustration and/or failure.

3. Where a Safety Plan is documented is key. Since a multi-component Safety Plan is difficult to remember in its entirety, advise your patients to save a written copy for retrieval during their moment of need. This may be in the form of a hand-written plan or a printout; it may also be a plan the clinician completes on a Safety Planning template in the EMR and emails to the patient after the visit with the patient’s consent. While these solutions are all an improvement over expecting the patient to remember all the details, they come with some drawbacks. Specifically, the patient may misplace their safety plan and then have difficulty finding it during their moment of need. Additionally, the patient may want to keep their Safety Plan private from other people they live with, and this may be difficult to accomplish with a written document. The MY3 Safety Planning app[2] provides a digital solution for Safety Planning that the patient can safely keep in their smartphone where it stays just a few clicks away. Patients can be encouraged to download and complete the form while in the visit where the Safety Plan is being collaboratively developed. The MY3 app is available for free for both iOS and Android devices. 

Safety Planning saves lives. A thoughtful process to build the Safety Plan better promotes acceptance and adherence to it from the individual experiencing thoughts of suicide, and promotes greater adoption in the long-run.

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