People plan out what to do in case of an emergency. From an early age, schools implement fire drills and teach children to stop, drop, and roll if their clothes catch fire. On every flight, attendants point out emergency exits and remind passengers what to do if the plane loses cabin pressure or winds up landing in a body of water. Barbara Stanley, Ph.D., a professor at Columbia University and director of the suicide prevention training program at New York State Psychiatric Institute, says knowing what to do ahead of time is essential because people in an emergency situation don’t think clearly. “In a crisis, we are panicked and not great at generating solutions. The same is true when someone is experiencing an acute suicidal state. It’s a dire event that requires taking steps to prevent acting on suicidal thoughts.” She says while school fires are a rarity, globally, according to the World Health Organization, about 800,000 people die of suicide each year, which translates to a suicide every 40 seconds. Dr. Stanley says it’s no less critical for people to have a plan in place in case of a psychiatric crisis than any other type of emergency.
Dr. Stanley and Gregory K. Brown, Ph.D., research associate professor at the University of Pennsylvania and director of the Center for the Prevention of Suicide, developed a critical brief suicide prevention intervention they would later call the Safety Planning Intervention (SPI), though at the time they had no idea of its potential impact. Dr. Stanley says they created the plan during a study with suicidal adolescents to help participants during the gap of time between entering treatment following a suicide attempt and having sufficient psychotherapy to prevent further suicidal behaviors. Dr. Stanley and Dr. Brown were part of a group of investigators comparing the efficacy of SSRIs and a psychotherapy they had developed for young people who were depressed and had recently attempted suicide. They wanted the teens to remain outpatient to create as little disruption as possible in their lives, and they thought a safety plan would help. And it did. So much so that when the teens exited the study, they told the researchers that one of the strategies they found most helpful was the safety plan. “We weren’t thinking about it as a tool; we were thinking of it as something to keep them safe until they got real treatment, which was our psychotherapy or medication. It turned my thinking on its head.”
Reexamining her thoughts on suicide and suicidality, Dr. Stanley, pondered the chasms in literature. The industry has made remarkable strides in developing successful treatments for people experiencing suicidal ideation and behavior such as Dialectical behavior therapy (DBT), Cognitive behavioral therapy (CBT), and Cognitive Therapy for Suicide Prevention (CT-SP). The trouble is that each takes a long time, several months to a year, depending on the treatment route, which creates a period of critical vulnerability. In fact, people have a high risk of suicide in the first month of discharge from an ER or psychiatric hospitalization. According to a research review that examined 48 studies and was published this year in the Harvard Review of Psychiatry, 26% of all suicidal acts took place within the first month after discharge, 40% within three months, and 73% within a year. Dr. Stanley realized the brief safety planning intervention could step into that space after discharge from an ER or psychiatric hospital, and go hand-in-hand with long-term treatments. She says yes, people need help with the underlying reasons for feeling suicidal—perhaps they’re feeling depressed, have lots of psycho-social stressors, or are experiencing long-term issues like severe substance abuse—but layered on top, people also experience acute crises that may last only minutes or hours. “There’s a need for two types of interventions: brief ones to deal with acute crisis and those that are longer-term to deal with underlying issues such as depression or serious life stressors. The brief intervention was the missing piece.”
What Dr. Stanley and Dr. Brown developed is a life-saving intervention that’s now used in ERs throughout the United States and around the world. She says for many people who go to the ER experiencing suicidal ideation, the safety plan is their first and last interaction about suicidality within the healthcare system: roughly 70% won’t go to their first outpatient appointment. The intervention reduces people’s imminent risk, empowers them to identify the helpers in their lives, and it also plays a critical role in follow up. In fact, those who receive the SPI along with structured follow-up fair better than those who don’t. In a recent study published by JAMA, Dr. Stanley, Dr. Brown, and colleagues found that patients who received the intervention were about 50% less likely to exhibit suicidal behavior and over twice as likely to get treatment during the 6-month follow-up period than cohorts who received usual care. Like long-term treatment, each safety plan is individualized, listing out concrete steps the person can take when feeling suicidal, including warning signs that a crisis may be developing, internal coping strategies, people and social settings that provided distraction, people as well as professionals and agencies to reach out to for help, how to make an environment safe, and critical resources.
The SPI, says Dr. Stanley, is just one necessary component of suicide prevention among others, such as population-based prevention, screening, identification and assessment, suicide-specific psychotherapy, suicide-specific pharmacology and brain stimulation, and a robust crisis care continuum. Similar to Dr. Jeffrey Swanson’s thoughts on Psychiatric Advance Directives (PADs), Dr. Stanley says an SPI is only as good as its implementation. She says some clinicians treat it as a form to be filled out, failing to go through the initial parts that create a narrative. “That’s where you really understand a person’s warning signs, and when you take a little time with them, you also develop a small bit of a relationship, which helps the intervention to go smoothly. If you go through it like it’s just another form to fill out, then mostly I say don’t bother. You have to breathe life into it. Otherwise, it limits the potential effectiveness.” For it to work as a clinical intervention, Dr. Stanley says clinicians need to treat the SPI as more than just a piece of paper, working collaboratively with patients to help them through each step as well as identifying obstacles and discussing ways around them. This includes navigating practical elements like suggesting that the patient communicates with people on the list of supports, asking them if they want to be on the safety plan. If not, she says they aren’t the best people to add. “It also means talking patients through how to ensure that the plan is accessible. Does that include taking photos of the intervention and storing it on their phone? Or making copies and hanging them up around the home as a reminder of what to do? Clinicians taking the time and care to go through each element of the plan is what makes it an effective intervention. “It takes about 45 minutes and has the potential to save someone’s life.”
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