This is not to take the place of a suicide assessment, or professionally-developed safety plan
This post is about the many creative ways to apply the concept of suicide safety planning in order to support a loved one (or yourself) when they are emotionally vulnerable, in crisis, or at risk of making a decision that can result in a threat to life such as suicide or addiction relapse. We can call it the emotional crisis safety plan.
It’s a way to remind an individual of their connection to life, healthy coping strategies they have identified as helpful, as well as people and trusted resources they can reach out to prior to and in crisis situations. The simplest and one of the most effective is the index card created in one’s own handwriting which any of us can do by ourselves or with our loved one.*
This is not the end-all, be-all of crisis safety plans but it embodies what research has shown is the most important part of a suicide safety plan and it can be the bridge that keeps a loved one safe and connected to life.
Best therapeutic practices to use with suicidal individuals include:
Just so you know the process for suicide prevention.
Source for this list: Kim O’Brien PhD, LICSW
- Safety planning (with ALL suicidal individuals)
- Cognitive Behavioral Therapy (for cognitive targets; e.g., CBT-SP)
- Dialectical Behavior Therapy (for emotional and interpersonal targets)
- Continual assessment and management of risk (e.g., CAMS)
This process usually starts with a suicide risk screening and if positive, a suicide risk assessment prior to creating a suicide prevention safety plan. Usually, there is a discussion on the removal of means (I’ll cover this important topic in another post) or reducing access to means, and then a treatment plan for the patient that identifies triggers and teaches coping strategies.
This process might also include other steps such as a psychological evaluation, family therapy, and medical intervention to stabilize an individual. Inpatient hospitalization is not the default choice simply because the wait times for a bed in the ER and process overall can be traumatizing to the individual.
There are subheads so topics are easy to find. First, the different kinds of plans that are widely available.
Available Safety Plans
A safety plan is not a magic document that when rubbed makes all the hurt go away. It’s simply the result of a conversation or thinking process in rational thought of what matters most and who to connect with when that person is not feeling well. It’s a way to manage the pain when it’s intense.
These are the suicide safety plans that are widely available:
- Suicide Safety Plan Template (Source: Brown Stanley Safety Plan)
- My Suicide Safety Plan (source: Dr. Tracey Marks. Same plan but less intimidating layout.)
- Safety Plan App for mobile phones
- Apple
- Google Play
- Hope by CAMH (iPhone)
- The Index Card hack. This is where we’ll start since it’s the one everyone can do.
The index card hack embodies the most important characteristics of a plan and a strategy to help support life.
The index card safety plan hack*
Here’s the prescription that goes with the card you will create:
- You or you and a loved one create an index card crisis safety plan
- Fold it and put it in a wallet (handbag, pocket, phone pocket etc)
- Keep the card with you at all times
- When struggling emotionally, review the card at least 3X per day to connect to life and remind that individual of what is important
- Alternatives are: Putting the info into the safety plan app (links below), taking a photo of it and making it searchable and easy to find, or use a memo pad on your phone. Research has shown that an index card with reasons for living written in one’s own handwriting and kept on the person is an effective survival strategy.*
You can do this with yourself, your child, spouse, sibling, best friend, students, etc. I’ve included a simplified version as well as one with more info for those feeling ambitious. Once again, this is not a replacement for safety planning with a suicide-trained clinician but it’s a crisis plan we can do now for use when we need it. Because everyone at some point in their lives has an emotional crisis of some kind and needs support.
First are the templates, starting with a simpler version anyone can do. Then examples of what each can look like.
SIDE ONE are reasons for living. This can take some time and that’s OK and important that we give ourselves or loved ones the opportunity to think about this.
SIMPLE SIDE TWO:
- Your coping strategies in the moment of struggling with suicidal or other self-destructive thoughts. These are distractions or triggers that can prevent the person from attempting or relapsing. (e.g. Biking outside, taking dog for a walk, watching dry bar comedy etc.)
- Then people and crisis numbers to call when one is struggling. It can be before a person reaches crisis and when in crisis. (e.g. friends and family members you’d call as well as at least one crisis resource such as Crisis Text 741-741, “Stop, Drop & Roll Emotional Emergency video,” Suicide Prevention Lifeline 1-800-273-8255)
A person can also list all the info on one side, as well. Whatever works for that individual.
FYI Crisis Resources:
USA 988
USA Crisis Text 741-741
USA Crisis Line for LGBTQ Youth 1-866-488-7386
USA Crisis Text for LGBTQ Youth 678-678
USA TransLifeline 1-833-456-4566
USA Suicide Prevention Lifeline & Chat for the Deaf or Hearing impaired. Or dial 711 then 1-800-273-8255
United Kingdom Samaritans 116 123
Australia Crisis Line 13 11 14
Canada Crisis Line 1-833-456-4566
Canada TransLifeline 877-330-6366
International suicide hotlines
ALTERNATE SIDE TWO: This is a bit more work, takes more thinking. The difference is adding the warning signs.
- Warning Signs: Ask yourself or the person who struggles what the warning signs are prior to feeling suicidal. (e.g. tend to isolate, become irritable, get headaches, pace, don’t want to get out of bed)
- Coping strategies/distractions: In the moment of struggling with suicidal thoughts. These are distractions that can prevent the person from attempting, relapsing, engaging in self-destructive behavior. (e.g. Engage with the Not OK app, watch old Seinfeld episodes, call someone in your AA group, cuddle with your cats, take dog for a walk)
- People to reach out to: Friends who will listen, come over, talk without judging (e.g. best friend, parent, sister, teacher/school counselor, your therapist, parent, regular people you love and trust-one of which is a trusted adult)
- Crisis support: Crisis resources and numbers to call when one is struggling. At least one crisis resource. (e.g. Crisis Text 741-741, “Stop, Drop & Roll Emotional Emergency video,” Suicide Prevention Lifeline 1-800-273-8255)
Index card examples
INDEX CARD SIDE ONE– Reasons for Living
This is the most important side. It’s what a struggling person will look at the most often and what will remind that person about their connection to life or their purpose.
When someone is struggling, that person should fold this in half, pull it out of a pocket, and review it three or more times a day.
If my son Charles was alive, the card above would have been what his looked like.
Notice how this one is focused on triggering positive memories that give the person reason to live.
Reasons for living can be:
An animal, family members, best friend, a memory such as a vacation or get together that triggers good memories. A story about someone’s kindness, mention of a special gift (stuff animal, small object) that has meaning and triggers pleasant thoughts, a hobby or sport that one is passionate about.
INDEX CARD SIDE TWO
SIMPLE SIDE TWO
ALTERNATE SIDE TWO: Sometimes figuring out the warning signs without clinical support can be a challenge. Mainly, we want the person struggling to know the coping strategies and the crisis support and as non-pros, we can handle that. However, if you want to go deeper, here are the examples.
Teachers can use the simple index card as a class activity and the how-to post and download are at this link.
Example of Brown Stanley Safety Plan
Example of Tracy Marks Safety Plan
This plan was created by Anne Moss Rogers and a college student.
Suicide Safety Plan App
This has the same information in it but is available on a phone as an app so that it’s accessible all of the time. Since people are on their phones, it might help to have it in an app they can access when they start to feel the triggers that precede a suicidal crisis. The person can share the plan with a loved one.
Resources:
- Cognitive Therapy for Suicidal Patients (CT-SP)– A CBT-based treatment protocol for those with suicidal thoughts
- Not OK app
- For clinicians: Adolescent Safety and Coping Plan. O’Brien, K., Almeida, J., View, L., Schofield, M., Hall, W., Aguinaldo, L.D., Ryan, C.A., & Maneta , E. (2019). A safety and coping planning intervention for suicidal adolescents in acute psychiatric care. Cognitive and Behavioral Practice
- ASQ Suicide Screening Tool for those 10 years and up. Developed by NIMH
*Sources:
*The index card hack is based on Veteran and psychologist Dr. Craig Bryan’s evidence-based “Crisis Response Planning” intervention which includes:
- Personal warning signs: personal indicators of an emerging emotional crisis.
- Self-management strategies: simple strategies that can be used to help reduce stress or serve as a distraction.
- Reasons for living: things that provide a sense of purpose or meaning in life.
- Social support: people who provide support or elevate one’s mood during tough times (e.g., friends, family members).
- Professional crisis support: contact information for health care providers, crisis hotlines, and emergency services.
Here is the 4-minute video for clinicians on the CRP and the podcast episode 99 with Dr. Craig Bryan on Hope Illuminated with Dr. Sally Spencer-Thomas.
