Information for Psychotherapists
Regardless of the specific therapeutic approach or school, there exists in therapeutic literature the idea that people seeking advice should be given clear actions to take when they are in a psychological crisis or feel that they are tending toward this state. When conceiving of the safety plan app we analysed various safety plans and discussed the pros and cons with therapeutic specialists. The most frequent similarity between all of the safety plans that we considered was the structure: it was common for the person seeking advice to begin by trying to make independent use of helpful measures. If these do not make a difference or the affected person doesn’t feel able to carry them out, external help should be sought out.
The structure that we chose is based on the structure from Barbara Stanley & Gregory Brown (2009, 2012), whose ‘Safety Planning Intervention’ was classified as Best Practice by the Suicide Prevention Resource Center. If you do not need one of the suggested categories for a safety plan, you can simply leave it out.
When is a Safety Plan Useful?
Safety plans were originally designed particularly for suicidal crises, but they are also suitable for less serious crises. With the term psychological crisis we are referring to a state of emotional confusion, in which an individual tends towards dysfunctional thoughts and actions. These could be suicidal thoughts or the urge to self-harming behaviour, but it includes the urge to over-eat, to induce vomiting or to ingest psychotropic substances, as well as other states of anxiety. The safety plan is designed to help people overcome these states on their own or with the help of others. The App helps those who are affected to implement this by making the safety plan always available and by simplifying the usage.
When creating a safety plan, it is important that this is done in collaboration with the person who will be using it (Jobes, 2006). This person should use their own words as much as possible when formulating the measures and should note down the steps themselves. It is also worth considering whether the person being treated should be obligated in some way to follow the safety plan, for example through a contract or agreement between the person seeking advice and the therapeutic professional.
Identify risk factors and early warning signs: In order for an individual to know when they should use the safety plan, it is necessary to begin by identifying early warning signs. The person seeking advice should attempt to recognise these independently in their daily life. At this point the increase of self-awareness is also helpful. Early warning signs are the first to appear before an impending crisis and can, for example, be particular situations, images, thoughts, patterns of thinking, feelings or forms of behaviour. The early warning signs must by all means be taken seriously so that the individual can react in time and can counteract the crisis. A delayed response can often be a critical mistake.
With individuals that feel the urge to abuse certain objects (e.g. weapons) or substances (e.g. alcohol, medicines, drugs) in a crisis, it should be considered whether their access to these can be restricted.
Structure of the Safety Plan
In the Safety Plan App there are four categories of actions to be taken. If a particular category is not relevant for an individual, it can easily be left out. As many steps as required can be added to each category. Do bear in mind, however, that the safety plan should be a simple, clear and precise support. The plan should not consist in numerous options that the individual has to choose between. It is rather to be understood as a single, unambiguous set of instructions.
The Four Categories in your Safety Plan
You can add as many steps as you would like to your safety plan from the four different categories.
In the event of a crisis follow your safety plan through step by step, starting at the top and working your way down to the bottom.
1. Coping Strategies
Sometimes referred to as ‘Skills’, these are activities that the person seeking advice can carry out independently to manage the crisis and improve their situation. The most effective strategy will vary from person to person. Since there are hundreds of possible strategies, we recommend that you discuss with the individual being treated which measures have proven to be helpful in the past. Alternatively, you could provide them with a list of possible strategies and ask them to mark the ones that might be helpful. It is recommended that the identified strategies are first tried out and it then decided on this basis which are most suitable for the safety plan.
A particular effort should be made when choosing suitable coping strategies. Effective strategies help the person seeking advice to feel independent and to be more confident that they can manage the crisis on their own.
Some examples of coping strategies are going on a walk, listening to inspiring music, having a (cold) shower, doing sport, taking up a hobby, reading, cleaning or tidying up. A list of further examples can be found in various therapy manuals.
The choice of coping strategies should always be made together with the person seeking advice, especially when the strategies trigger extreme sensory stimuli (e.g. smelling ammonia). It is advantageous if a strategy is enjoyable, creates a feeling of effectiveness and ability, or is meaningful.
Once the coping strategies have been selected, it is a good idea to go through them again with the person seeking advice to see if there could be any difficulties when putting them into practice. It is best if it is possible to use these strategies at any time, regardless of the location. The person seeking advice should be able to make use of these strategies even in a crisis. Feel free to collate more strategies and sort them according to the expected feasibility and effectiveness.To Do:
- Identify helpful coping strategies
- Check for effectiveness and feasibility
2. People and Places for Distraction
The idea behind this idea is that clients often do not give in to dysfunctional patterns of behaviour when they are in contact with other people. This contact can also distract them from problematic thoughts and emotions, which can also improve general wellbeing. It is unlikely, for example, that someone with the urge to harm themselves will do this when they are in a public cafe or walking with a friend. It is important, however, that the particular place does not facilitate dysfunctional behaviour. For someone being treated for an addiction, the addictive substance (e.g. alcohol) should not be on offer at this location.To Do:
- Identify people and places for distraction
- Check the results for ‘dangers’
3. Support Contacts
In this category you should identify people who can actively help the person seeking advice to cope. These will often already know who they trust and who will be able to help them in a crisis. It is, however, important, that the support contact is also willing to be contacted in such a situation and sees themselves as able to help. Once the person seeking advice has identified a suitable support contact, you or the person seeking advice should discuss with the support contact whether they are prepared to help and explain how they should act in the event of a crisis. Throughout this stage it is important to pay attention to the individual wishes of the person seeking advice. It can be helpful to discuss the entire safety plan with the support contact so that they know which coping strategies are effective and understand where and how professional help can be involved. It is best to address the fears and worries of the support contact directly and explain to them how they should act if they feel overwhelmed in a crisis situation.To Do:
- Identify possible support contacts
- Check whether these people are prepared to help and let them know how to act in the event of a crisis
4. Professional Help and Counselling Services
In this category you can note down therapists, doctors, carers, counselling services, other professional contact points and a number for the emergency services. It is important that at least one of these contact points is available at all times: 24 hours a day, 7 days a week. You should discuss with the person seeking advice what they expect when they contact these professional organisations and identify any obstacles. It may be, for example, that the person seeking advice is afraid of compulsory admission to a clinic. Discuss these worries with them and try to take these worries away from them. You should only enter people and contact points which the person seeking advice is also prepared to get in touch with.To Do:
- Identify professional contacts / organisations (at least one of which is always available)
- Check willingness to get in touch and identify any obstacles
Once the safety plan has been created, go through it once again with the person seeking advice and check how likely it is that each of the stages will really be carried out in a crisis. The person seeking advice should neither feel overwhelmed by the plan nor be worried about carrying out any of the steps for any reason. If you identify obstacles, these should be openly discussed with the client and, if necessary, the plan should be adapted accordingly. Role plays can help to prepare the person seeking advice for difficult situations and to identify obstacles at the same time.It can also be helpful to ask the client themselves to explain what they find particularly helpful about the safety plan.
Make sure that the person being treated does not just enter the safety in the App but also writes it down on a piece of paper that is, for example, stored in their wallet. Whilst the App makes it easier to use the safety plan, the person being treated must always be able to access their plan, even if, for example, their smartphone battery runs out. If you have any comments, questions or thoughts, please do not hesitate to contact us! We are very thankful for your feedback.
Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: The Guilford Press.
Stanley, B., Brown, G. K. (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19, 256-264.
Stanley, B., Brown, G. K., Brent, D., Wells, K., Poling, K., Curry, J., et al. (2009). Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment model, feasibility and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1005-1013.
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