Earlier today I had a 90-minute Zoom meeting with the staff from Bridgercare of Bozeman, Montana. Bridgercare is a medical clinic focusing on sexual and reproductive health. Our meeting’s purpose was to provide staff with training on how to integrate a strengths-based approach to suicide assessment and treatment into their usual patient care.
It’s probably no big surprise to hear this, but even through Zoom, the Bridgercare staff was fabulous. They’re clearly dedicated to the safety and wellbeing of their patients. I enjoyed meeting them and wish I could have been there live and in-person (but, having gotten my second vaccine shot today, more live and in-person events are in my future!).
One member of the medical staff asked if I had material on how to enhance the safety planning process with patients. After fumbling the question for a while, I remembered that I included a safety planning case example in Chapter 8 of our suicide book. I’ve included the excerpt below. Although the case is written in my voice, as you read through, think about how you might put it into your voice.
This case description illustrates a positive working relationship and outcome. Just to make sure you know that I’m not too Pollyannaish about suicide-related work, the whole book also includes cases and situations with less positive scenarios and outcomes.
Below, the counselor is discussing a safety plan with a 21-year-old cisgender female college senior named Kayla. Kayla was attending a large state university and living off campus in a small apartment. In this case, Kayla was social distancing in compliance with state stay-at-home orders; the session was conducted remotely, via an online video-based HIPAA-compliant platform (e.g., Doxy.me, SimplePractice, etc.).
The Opening and Unique Suicide Warning Signs
Counselor: Kayla, I’m putting your name on the top of this form [holds form up to camera]. It’s called a safety planning form. Some very smart people made up this form to help people stay safe. There are six questions. We’re supposed to fill it out together. If you hate it when we’re done, we can toss it in the trash. Okay?
Kayla: Okay. That’s possible.
Counselor: That would be fine. Here’s the first question. I’m just going to read them to you. Then you answer, I’ll write down your answers, and then we talk about your answer. What are the signs, in yourself or in your environment that will be a warning that tells you that you need to do something to keep yourself safe?
Kayla: I just like feel a wave of sadness and defeat. Like my life means nothing. Like I’m a damaged, bad person who should die.
Counselor: Okay. A wave of sadness and defeat. How will you know that wave has come? What do you feel in your body or think in your brain?
Kayla: I feel a physical ache. I think about being abused. I think horrible thoughts.
Counselor: I’m writing down, “Wave of sadness and defeat, and physical ache, and thoughts of being damaged, bad, and abused.” Those are all signs that you should follow this safety plan.
Kayla: Also, being home alone at night.
In this initial exchange the counselor empowers Kayla to reject the plan if she wants to. Offering to let Kayla reject the plan probably makes it more likely for her to take ownership of the plan. If Kayla ends up rejecting the plan, that information becomes part of the overall assessment and guides treatment decision-making.
Kayla immediately engages in the process. Specifically, her trauma-based thoughts of being damaged and bad could be fruitful therapeutic grist for cognitive processing therapy or EMDR, both of which address trauma and focus on beliefs about the self. However, when using the SPI, it’s best to stay focused on the SPI, and save the deeper therapeutic content for later. The counselor could (and should) have said, “For now, we’re working on this plan. But later on, if you want, we can start working on your feelings of being damaged and bad.”
Personal Coping Strategies
Counselor: What can you do in the moment to cope with suicidal thoughts and feelings?
Kayla: Look. I could cut myself to feel better, but nobody wants me to do that.
Counselor: I’m sure it’s true that people don’t want you cutting. I also think it’s true that people would rather have you cut yourself than kill yourself. If cutting keeps you alive, we should put it in the plan, at least for now.
Kayla: I think it should be there then.
Counselor: Okay. So, cutting goes on here as a method for calming or soothing yourself. Have I got that right?
Kayla: Yeah. It calms me down when I’m upset.
Counselor: What else could calm you down or distract you from suicidal thoughts?
Kayla: I could listen to music or call a friend.
Counselor: Great. I’m writing those ideas into the plan right now.
Brainstorming coping responses is similar to other processes discussed in chapter 5 (problem-solving and alternatives to suicide). One key principle is to accept all responses before evaluating them later. In the preceding interaction, the counselor accepts that cutting might be a viable (even if not preferred) short-term coping strategy, and then continues to nudge Kayla to generate additional coping ideas. Although cutting isn’t addressed in this case example, after developing the safety plan, therapeutic conversations about cutting and alternatives to cutting, should become a part of ongoing counseling (see Kress et al., 2008; Stargell et al., 2017).
Social Contacts and Settings
Counselor: I’m wondering about those times when you’re alone. Who could you be with to stay safe? Even if it’s only for you to distract yourself?
Kayla: I have a friend named Monroe. He’s crazy. He’s always happy. Sometimes he annoys me, but he’s a good distraction.
Counselor: Monroe sounds like a great distraction. He’s in the plan. Are you able to see him in person, or would you do Facetime or a Zoom call.
Kayla: He lives in the apartment building and we could meet up outside.
Counselor: That sounds great. Who else?
Kayla: I can always call my parents, but when I do, I feel like failure. I’m an adult.
Counselor: If you’re feeling suicidal, would your parents want you to call?
Counselor: Okay then. Let’s put your parents down. We can talk more later about how calling them might make you feel.
The counselor does a good job of getting Kayla to be specific about how she could connect with Monroe. Overall, Kayla doesn’t have an extensive social support network. Expanding that network will likely become an important goal for counseling.
People Whom I Can Ask Help
Counselor: This question is similar to the last one, but a little different. Instead of people who are distracting, now I’m wondering who you can turn to if you’re in crisis?
Kayla: Monroe wouldn’t be the right person for that.
Counselor: Not Monroe. But who would be right for that?
Kayla: My parents, I guess. And my aunt, Sarah. She’s always been there for me. I could call her if I need to. And my grandma.
Counselor: Good. That’s four. Your mom, your dad, your aunt Sarah, and your grandma. Are they around here, or would you call or text them?
Kayla: My parents and aunt live close by, but we’d probably just Facetime because they’re older I don’t want them to get COVID. My grandma lives in Minnesota.
While generating lists, it’s useful to draw clients into being even more specific than illustrated in this exchange. For example, as Kayla identifies people to call, getting specific about texting or calling, where the person might be, and what to do if there’s no answer, is good practice. Role playing a call or text can be useful, because rehearsing behaviors make them more likely to occur.
Mental Health Professionals or Agencies to Contact
Counselor: How about professionals or agencies that you can call if you’re in a crisis?
Kayla: I don’t have anyone.
Counselor: Wait. You need to put me here. I should be on the list. I can be available for short calls Sunday through Thursday evenings up until 9pm.
Counselor: And there’s 9-1-1, right? You can always call 9-1-1. In an emergency, that’s what you do. There’s also a new suicide hotline number, 9-8-8. I’m going to write that number down too. You don’t have to call any number, but it’s good to have them just in case you do want to call for professional help during a crisis. The other thing to remember about calling hotlines is that you may get someone you don’t like or don’t connect with. If that happens, keep trying, but also, jot down a few notes so you can tell me about it.
In the preceding exchange, the counselor offers to be a limited option. Whether you provide a personal contact number is up to you. Whatever you do, spell it out in your informed consent and have boundaries around the times when communications with you are acceptable. Because calling hotlines may or may not feel helpful, empowering Kayla to critique her hotline experience and then report it to the counselor might increase her willingness to call.
How Can I Make My Environment Safe?
Counselor: This last question has to do with how you can make your environment safe. We’ve talked about various things, like how you can cope and who you can call. Now we need to talk about whether there’s anything dangerous in your home, anything that could be used to kill yourself if you were suddenly suicidal.
Kayla: Yeah. Well I bought a hand-gun last year. That’s how I would do it.
Counselor: Right. Thanks for telling me about the gun. Can I just tell you what I’m thinking right now?
Counselor: With guns and suicide, there are two good options. One is for you to give it to someone for now, until you’re feeling better. The other is for you to safely store the gun or get a trigger lock. I’m just being totally honest with you about this. The reason we should get your gun locked up or given to your parents or someone else, is because most of the time, people are intensely suicidal for only 5 or 10 or maybe 30 minutes. During that intense time, people can do things they later regret. Most people who make a suicide attempt don’t make another attempt. It’s usually a one-time thing. My main goal is for you to be safe.
Kayla: But I’m not planning to use the gun or anything.
Counselor: Right. That’s great. But let’s say your Aunt Sarah was suicidal and she had a gun, would you be willing to keep it for her if it made her safer?
Kayla: Of course I would.
Counselor: So, whether it’s you or your Aunt Sarah, we want to make sure suicide doesn’t happen because of one terrible moment.
The preceding is an example of psychoeducation around suicidality and safety planning. If you have a good rapport and connection with your client, the psychoeducation is likely to be well-received. If your rapport and connection is less good, then you’ll either need to work on the relationship, or take a more directive and authoritative role to promote your client’s safety.
Counselor: All right. I’ve written down your ideas for the safety plan. Now, I’m going to scan it and send it to you through our secure portal. As we’ve already discussed, we’re going to make a bigger plan for your counseling. But in the meantime, we need to keep you safe so we can do the counseling. Right now, you’ve got this safety plan you can use, and we can revise it if we need to. Okay?
Counselor: Kayla, thank you very much for working with me on this safety plan. I think we made a good plan together.
Kayla: Me too. I guess I won’t throw it in the trash.
Counselor: You’re pretty funny.
Please excuse any typos or bad grammar. The preceding is a pre-published (and pre-copyedited) version from my computer. To check out and possibly purchase the whole darn book, you can go here: https://imis.counseling.org/store/detail.aspx?id=78174