Reducing Suicide Risk With Safety Plans

A safety plan is something mental health professionals use when a child or adolescent says or does something that suggests they are at risk of doing something harmful. It’s usually triggered by talk of suicidal feelings, but it could also be thoughts of self-injury or harming someone else.

The safety plan is a series of steps the child or teen agrees to take to cope with their feelings without doing something harmful. It usually involves things they can do to calm down, distract themselves from painful feelings, and reach out for support. And it involves things both the teen and their parents will do to make their environment safer, by removing things they could use to hurt themselves.

The safety plan is usually prompted by something a teen says in a therapy session. “When some element of risk comes up in a session, we’ll drop the rest of the agenda at that moment and go into safety planning,” explains Joanna Stern, PsyD, senior director of the Mood Disorders Center at the Child Mind Institute. The clinician works with the teen to develop the plan, and after they’ve finished, it is shared with parents. The teen, the parents, and the clinician all sign the plan and agree to abide by it.

Obviously, there’s no guarantee that a teen will adhere to the plan if they have the urge to make a suicide attempt or some other harmful act. But it can save lives by diverting them until the urge passes.

That’s important because pre-teens and teenagers who make suicide attempts tend to be much more impulsive than adults. “Adults tend to make a plan — they will often have left a note. But that’s usually not the case with teenagers,” says Dr. Stern. “Making this safety plan for teens is to create more barriers, in that time when they’re at highest risk, to acting on those impulses.”

Making a safety plan involves engaging the teenager in a detailed discussion of what they are having the urge to do — if it’s suicide, how are they imagining doing it? Knowing those specifics enables the clinician and the teen to discuss how to make the teen’s environment safer. For instance, if the teen is thinking about cutting their wrists, the plan would involve reducing their access to knives by having parents make them inaccessible. If there is a risk of jumping from a window, the windows need to be locked.

“If it involves pills, then we have parents get a lockbox and lock all pills in there, including some over-the-counter stuff that can be lethal,” Dr. Stern adds. Parents might also be asked to provide extra supervision. “If you have a teen who is traveling independently and routinely goes into a pharmacy by themselves, you want to make sure that you are doing things to monitor their actions.”

It’s important to understand that the goal of the safety plan is not to solve distressing problems, but to help the person get through the next few hours or days when a potentially harmful impulse strikes. So the plan involves ways to redirect their thinking or attention until the urge passes.

A typical safety plan (see a sample here) includes a list of warning signs that both the teen and others can use to identify when they are at risk, and steps they can take to mitigate that risk. They often include language like the following:

• Triggers and warning signs that tell me when to use my plan (Examples: Feeling tense, thoughts of dying)

• Warning signs that others can see that show them I need help (Examples: Scared face, clenched fists)

• Coping strategies that I can do on my own to safely feel better (Examples: Practice relaxation skills, listen to calming music)

• People and social settings that provide distraction

• Things that make my environment safe (Examples: Preventing access to sharp objects, weapons, medications, and/or illegal substances)

• People that I can call for help and to feel safe (Examples: Parents, grandparents, trusted adult)

• Professionals/agencies that I can call for help and to feel safe (Examples: Therapist, school counselor, crisis center)

A safety plan typically also includes thoughts the teen might focus on that might mitigate against a suicidal impulse, such as reasons to stay alive. It’s not always easy. “Sometimes they say ‘Nothing. There’s nothing worth living for,’” Dr. Stern notes. “It’s really on us as the clinicians to work with them and say, ‘Okay, is there something even short term?’”

Sometimes, she adds, a teen will mention their dog — the thought of how sad their dog would be if they were gone could be a barrier to suicide. “It really is whatever might be the antidote in the moment to letting those dangerous thoughts and emotions take over.”

At the bottom of the safety plan is a section about steps to take if the plan isn’t working.

Dr. Stern helps parents identify the nearest emergency room and, if there are several, which has more expertise and resources for handling psychiatric emergencies in children and teenagers — such as a child psychiatry training program and an inpatient unit in case a child needs to be admitted.

She also discusses with parents how they will get to the ER. “Let’s talk through what might happen,” she tells them. “Can you take them yourself safely? Walk them there or go in a cab? What would be the circumstances where you would need to call 911 instead?”

The goal, she explains, is to get parents comfortable, ahead of time, with the idea of calling 911. “The other things we have on there are suicide prevention lifeline phone number and crisis text line.”

Once a plan is in place, Dr. Stern says the therapist checks in with the teen about the plan regularly.

The goal is to confirm that the teen still feels that the plan can keep them safe until their next session. If the child feels that the next session is too far away, she adds, “Then we’ll figure out a way to fit them in. Because we want to reinforce that help-seeking behavior before they engage in actions that are life-threatening.”

Parents can also remind kids of the plan if they’re concerned about a child’s safety. “If a teen comes back and says to them, ‘I know I promised this, but I just can’t do it,’ we talk to parents about what to do, such as take them to the ER, what to say when you take them to the ER — all of that stuff.”

While the concept of a safety plan is focused on helping the person get through the next few hours or days safely, there’s also a bigger picture. When kids have extremely powerful emotions, it’s important for them to learn that they don’t last forever.

When kids learn to use these coping strategies during the period of time where they feel the most intense, they are learning to tolerate distressing feelings in general, Dr. Stern explains, practicing getting through them without doing anything to make the situation worse.

The lesson, she says, is that even if they feel things aren’t okay, they can get through it: “Even if it is just as awful as I think it is. Even if it doesn’t get better in any big hurry, I can survive it for another day or I can survive it for another however many weeks.”

Another goal of the safety plan is to have not only the therapist but the teen’s parents know what the child is feeling. It can be very hard for parents to accept that their child is feeling bad enough to feel suicidal, but taking those feelings seriously is critical to keeping them safe. Validating their feelings by listening to them calmly, without judgment, is crucial to enlisting the child in not acting on impulses to harm themselves.  

Parents are often very reluctant to engage in a discussion of a child’s suicidal feelings because they’re afraid they will make the child more likely to act on them, or somehow give the child ideas. “But what we are doing is not putting ideas there that weren’t already there,” says Dr. Stern. “It’s really creating an open space to talk about it and to give parents language to talk about it.” Even if a child hasn’t expressed suicidal feelings directly, if a parent is worried that a child may be suicidal, the right thing to do is ask them about it.

And on the flip side, kids often feel they can’t tell their parents what they’re feeling because the parents will be too upset. That’s why it’s important for parents to be as calm as possible when discussing the safety plan. “This is not to say parents shouldn’t feel upset about it — of course they will. This is to say that parents need to use some of their own skills to get through that moment. Then you fall apart later. If you have a partner, or a support network, get the kids situated and then reach out and then fall apart.”

Sometimes Dr. Stern speaks to the parents separately before the safety plan discussion with the child. But sometimes there isn’t time. If the child is afraid of the parents’ response, Dr. Stern will mediate, keeping the focus on safety: “Here’s what your child needs from you right now.”

Or if the parents are reluctant to take a suicide threat seriously, she will say, “I understand you don’t want to do this, and you don’t want to take your child to the emergency room, because what if they’re bluffing? I hear you having the thought, ‘I don’t think my kid really means it.’ We have to err on the side of caution. Because what if they do? My priority is keeping them alive.”

A safety plan is not a guarantee of a child’s safety, but it is a concrete tool that can help everyone manage a situation that otherwise feels frightening and out of control. And by creating a structure to talk about it calmly, it can help an unhappy child take important steps towards dealing with their feelings without doing something harmful.