How to meaningfully engage someone who is skeptical about safety planning?

A clinician shared a difficult situation: She is working with an individual who has had risk routinely reassessed following two hospitalizations in the past year due to suicide attempts. After this experience, the person is hesitant to develop coping strategies or a safety plan, feeling this information was used against her in the past. 

We discussed some strategies to effectively engage clients who may be skeptical or hesitant to develop a plan or try new skills. 

1. Validate

•  Acknowledge their concerns. In some situations, individuals may feel that their coping skills will be turned against them. Questions such as 'Why didn’t you use your safety plan?' can cause anxiety and may undermine the therapeutic relationship. Reassure them that their experiences and emotions are valid, and commit to doing your best not to repeat that experience. 
• You could try conveying your concern by saying, “I’ve been thinking about what you said last time. It stuck with me that people used coping skills against you. I want to make an agreement with you that I’m going to try not to do that. If I did, would you tell me? I can see how that would feel pretty bad."

2. Instill hope

• Emphasize that our brains, and consequently our thoughts and feelings, are dynamic and capable of change. This perspective can help identify the capacity for change and growth. To make this concept tangible, encourage them to reflect on a skill they've learned, discussing the time and effort involved. This can illustrate how personal growth and changes in coping mechanisms over time are similar processes.

Collaborate

• Engaging different supports can be helpful, but for some it can also heighten anxiety and create a power imbalance, complicating the therapeutic process. You could seek permission to add other support and professionals to the safety plan, allowing collaboration on the person’s terms, ensuring personalized plans and strengthening the therapeutic relationship.

Here are five principles for best practice safety and contingency planning.

What challenges have you faced when creating a safety plan, and how have you overcome them? Comment below to share your experiences.

Related Resources

Mind Map of Challenges and Strategies for Contingency and Safety Planning

References

Ferguson, M., Rhodes, K., Loughhead, M., McIntyre, H., & Procter, N. (2022). The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review. Archives of Suicide Research, 26(3), 1022–1045. https://doi.org/10.1080/13811118.2021.1915217

Gamarra JM, Luciano MT, Gradus JL, Wiltsey Stirman S. Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System. Crisis. 2015;36(6):433-9. doi: 10.1027/0227-5910/a000345. PMID: 26648231; PMCID: PMC4675034. https://pubmed.ncbi.nlm.nih.gov/26648231/

Knapp, S. (2023). The essentials of creating effective safety planning-type interventions for suicidal patients. Practice Innovations, 8(2), 131–140. https://doi.org/10.1037/pri0000205

Green J., D, Kearns, J.C., Rosen, R.C., Keane, T. M., & Marx, B. P. (2018). Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk? Behavior Therapy, 49(6), 931-938. https://doi.org/10.1016/j.beth.2017.11.005

Nuij, C., Van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. British Journal of Psychiatry, 219(2), 419–426. https://doi.org/10.1192/bjp.2021.50

O’Connor, R. (2021). When It Is Darkest: Why People Die by Suicide and What We Can Do to Prevent It. National Geographic Books.

O’Connor, R.C., Smillie, S., McClelland, H. et al. SAFETEL: a pilot randomised controlled trial to assess the feasibility and acceptability of a safety planning and telephone follow-up intervention to reduce suicidal behaviour. Pilot Feasibility Stud 8, 156 (2022). https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-022-01081-5#citeas

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900.https://doi.org/10.1001/jamapsychiatry.2018.1776