First, we're going to discuss brief interventions, those that can take place in a single session. The most common of these is called crisis response planning or safety planning. These related interventions came about from two different families of researchers, but have much similarity. They are now standard practice for many mental health providers, healthcare systems, crisis lines, and others who work with individuals in suicidal crises. The goals of a crisis response or safety plan are simple. To use the information that a client has gathered, weathering their past suicidal experiences to build a plan to cope with future crises. You can think of this like having an emergency plan for a house fire or an escape route plotted out for a hurricane. It's much more effective to think through a plan before the crisis hits than it is once that crisis is at your doorstep or worse has already arrived. Crisis response plans and safety plans replace a very outdated and in fact iatrogenic practice called no suicide contracts. No suicide contracts used to be commonplace in hospitals and emergency departments. They involved asking a suicidal individual to sign the document, agreeing that they wouldn't attempt suicide. This was then counter signed by the physician. Sometimes the contract would include emergency services numbers that the suicidal individual was to reach out to if they were in need. The practice of using no suicide contracts does nothing to stop suicide. In fact, tends to make suicidal individuals feel more hopeless and less understood. Imagine if you walked into an ER at risk of a heart attack and the doctor just asked you to agree not to have one without giving you any treatment, medication or evaluation. Not very effective. These contracts tend to make the doctors and the hospitals feel better and safer from litigation, though, now that's very much not the case. A no suicide contract will do nothing to protect a provider in the event of a suicide death. Safety plans and crisis response plans on the other hand are quite different. Building a crisis response plan consists of two parts. First, the clinician will ask the client to tell the story of their most recent suicidal experience, which might be a recent suicide attempt or a struggle with suicidal thoughts. Through this retelling, the therapist will do their best to listen, understand how the crisis developed, grew and resolved, asking questions where needed to help clarify. The therapist will then work with the client to transition to building a plan for future crises, building on all the experiences they learned from their past experience. The plan has five parts that will go over now. It starts by identifying warning signs. What were the clues that the crisis was building? Specifically, that this was a suicidal crisis, not just an everyday stress or period of overwhelm. These warning signs will be different for everyone, but could include things like sleeping more, feeling your heart racing, snapping at others or having thoughts like, I feel so stuck. Once the client has generated a few warning signs that are relevant to them, the next step to put in is to identify strategies that help them cope with distress. What are some of the things they can do to ride out the storm? Like everything on this individualized plan, what ends up in this section varies widely. It could include things like taking a walk, taking deep breaths, watching a funny show, listening to a specific song, doing jumping jacks, taking a quick nap. Key to this section is to identify things that the suicidal individual already knows how to do. Things that have perhaps been helpful in the past. Additionally, it's important to make sure these things are doable in a stressful moment. Taking a long bath or going fishing might be activities that calm someone down, but they require some planning or an extended amount of time. You want things on here that are doable in many settings and that are doable with little advanced planning. The next section ask the individual to think about their reasons for living. Why are they making this plan to try to whether future suicidal crises? What kept them from acting on their suicidal desire in the past? What gets in the way of them killing themselves. Though that spark of life may be dealt at the moment, identifying and remembering some of the things that are important to them may help motivate them to try these strategies on the crisis response plan in the future. It also tends to help people connect to their spark in that moment, especially if they have a chance to describe a specific memory or a thing that keeps them going. Whether that's one of their children, a pet, their faith or a future goal they hope to accomplish. In the next section, the client lists people they can go to for support. Now this includes two types of people. Some may be people they can go to to talk about their problems or stresses. People where it's safe to tell them that they're in crisis and who would respond non-judgmentally, listen and understand. However, this section can also include people that an individual simply enjoys talking with for a distraction. For example, a chatty neighbor or coworker who always has a good joke or just somebody they like to shoot the breeze with? Even if the client doesn't talk about their deepest darkest feelings with these individuals, talking with them can serve as a welcome distraction and also as a reminder of social connection. Now, it's not uncommon for clients who have been struggling with mental illness or suicidality for a while to have a very diminished social circle. This is the one section of the plan that a client may choose to skip if there really isn't any appropriate source of social support in their life at the moment. In those cases, it might be helpful to think about a place the individual might like to go that can help them feel more connected or grounded to their community. Maybe even a library, a coffee shop or a park where they could just be around other people. The final section of the plan ask the individual to note down their professional supports. These could include a therapist, a psychiatrist or a family doctor. In this section, the client would also be asked to write down the local emergency department and CATECHOL emergency services, so they have those there as last resorts. If the individual tries each step on the plan and they're suicidal desired is not abate, it's important to reach out for professional help and to get assistance and staying safe. That's what those resources are there for. In the case of the crisis response plan, the plan is completed on a blank index card. It allows the plan to be fully customizable to the individual and is also usually small enough to fit in a purse or a wallet. At the end of the session, which usually takes about 30-40 minutes to complete, the therapist will review the plan with the client and check their perception of the likelihood that the client will use the plan. This helps the therapists know whether they need to go back and do some more work on the plan or whether it seems doable and reasonable to the client. Currently, this intervention is used in the context of longer-term therapy, as well as a standalone intervention at crisis centers, in hospital emergency rooms, and by emergency services. Now importantly, while we have multiple studies that show that safety plans and crisis response plans help, they reduce the risk of future suicide attempts substantially. We don't yet know exactly why. It could be that the plan is helpful because it's just that a plan. So when suicidal thoughts come up in the future, the individual knows what to do and can follow the steps. It may be because having a plan builds hope and cognitive flexibility. Helping the suicidal individuals see what is difficult with those blinders of suicide on that there are times that they felt better and that there are things that they still value in their life. Or perhaps the impact of the crisis response or safety plan comes from the connection and understanding generated when the individual works with a counselor directly on their suicidal desire. Further research is needed to help us clarify how this brief intervention works so that it can be disseminated most effectively and efficiently. Watch the linked clip here to learn more about brief interventions for suicide and then next we'll talk about more moderate length interventions.
