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Creating a safety plan for suicidal ideation gives clients a concrete, personalized plan they can use when suicidal thoughts intensify. Rather than relying on someone to figure out what to do in the middle of a crisis, the plan identifies warning signs, coping strategies, people and places that can provide support, professional resources, and ways to make their environment safer.
As a therapist, I think one of the most important things to remember is that a safety plan for suicidal ideation shouldn't just be a form we complete and put in the client's chart. It needs to be something the client could realistically use when they are overwhelmed and may have less access to the problem-solving skills they have when they are regulated.
The Stanley-Brown safety planning intervention gives clinicians an evidence-based framework for doing exactly that.
What is the Stanley-Brown safety planning intervention?
The Stanley-Brown safety planning intervention is a brief, collaborative intervention developed by Barbara Stanley, PhD, and Gregory Brown, PhD, for individuals experiencing suicidal thoughts or behaviors.
The intervention involves creating a prioritized list of strategies the person can use during a suicidal crisis. Importantly, the therapist doesn't simply create the plan for the client. The Stanley-Brown safety planning intervention is collaborative and individualized to that person's warning signs, coping strategies, relationships, environment, and resources.
Research also supports this approach. A 2018 JAMA Psychiatry study found that patients receiving the Stanley-Brown safety planning intervention plus structured follow-up after an emergency department visit had fewer subsequent suicidal behaviors and greater engagement with outpatient mental health care compared with usual care.
What should you include in a safety plan for suicidal ideation?
The Stanley-Brown safety planning intervention includes six primary steps. A safety plan for suicidal ideation should walk the client through these steps in an order they can follow if a crisis develops.
1. Identify warning signs
Start by helping the client recognize signs that a suicidal crisis may be developing.
These can include thoughts, emotions, behaviors, situations, or physical sensations. One client might notice themselves withdrawing from everyone around them. Another might experience hopeless thoughts, stop sleeping, or become increasingly agitated.
The more specific the warning signs are, the more useful the safety plan for suicidal ideation becomes. As a provider, be sure not to shy away from this part. Naming specific signs is critical as it decreases the taboo and opens the client up to feeling safe about these thoughts and feelings.
2. Identify internal coping strategies
Next, identify things the client can do independently to help them get through the immediate period of distress without acting on suicidal thoughts.
These should be realistic for that particular client. Depending on the person, coping strategies might include going for a walk, taking a shower, listening to music, playing with a pet, exercising, or using grounding techniques.
This isn't necessarily about making the distress disappear. Sometimes the immediate goal is simply helping the client create enough space between an urge and an action to move to the next step in the plan.
3. Identify people and places that provide distraction
The next step of the Stanley-Brown safety planning intervention involves identifying people or social settings that can provide healthy distraction.
This might include going to a family member's house, sitting in a coffee shop, spending time with a friend, or going somewhere the client feels connected to other people.
Get specific. “Be around people” is much harder to act on during a crisis than “go to my sister's house.”
4. Identify people the client can ask for help
The next step in enacting a safety plan for suicidal ideation involves identifying people the client can tell directly that they're struggling.
Ask who they would actually feel comfortable contacting during a crisis. Include names and contact information in the safety plan for suicidal ideation whenever possible.
It can also be useful to talk through what reaching out might sound like and possibly explore letting people on their list know ahead of time that they could be reaching out. A client may know they can call their best friend but still freeze when imagining what they're supposed to say. Having prepped their friend can help them move through a freeze more effectively.
5. List professionals and crisis resources
A safety plan for suicidal ideation should also include the professionals and crisis services the client can contact when additional support is needed.
Depending on the client's situation, this may include their therapist, psychiatrist, local crisis resources, 988 Suicide & Crisis Lifeline, or emergency services.
Clinicians should be clear about their own availability as well. A client shouldn't leave with a plan that assumes their therapist will answer a phone call at 2 AM or conflate the therapist with emergency services. Depending on your practice policies and the client's level of risk, it can also help to explain what will happen if they call you in a crisis, such as being directed to the nearest emergency room.
If you or a client is in crisis: Call or text 988, or chat at 988lifeline.org, to reach the 988 Suicide & Crisis Lifeline, available 24/7. In an emergency, call 911.
6. Make the environment safer
Finally, the Stanley-Brown safety planning intervention addresses reducing access to potentially lethal means.
This part of crisis intervention planning should be specific to the client's circumstances and level of risk. The goal is to collaboratively identify practical ways to create more time and distance between a suicidal crisis and access to a lethal method.
How can the Columbia Suicide Severity Rating Scale help?
Before creating or updating a safety plan for suicidal ideation, clinicians need to understand the nature and severity of the client's suicidal thoughts and behaviors.
The Columbia Suicide Severity Rating Scale (C-SSRS), also called the Columbia Protocol, is one tool clinicians can use as part of that process. It uses direct questions to assess suicidal ideation and behavior, including the presence and recency of suicidal thoughts, preparatory behaviors, and suicide attempts.
However, a screening tool doesn't replace clinical judgment or a comprehensive assessment. The Columbia Suicide Severity Rating Scale can provide valuable information that informs your assessment, but clinicians still need to consider the client's history, current circumstances, risk and protective factors, access to means, and other relevant clinical information.
Safety plan vs. no-suicide contract: What’s the difference?
When considering a safety plan vs. no-suicide contract, the biggest difference is what you're asking the client to do.
A no-suicide contract generally involves asking a client to promise that they won't attempt suicide. A safety plan for suicidal ideation, on the other hand, identifies concrete actions the client can take when suicidal thoughts or urges increase.
A promise not to act doesn't tell someone what to do when they're sitting alone at night and their suicidal thoughts suddenly become more intense.
The Stanley-Brown safety planning intervention gives them actionable next steps.
For clinicians considering a safety plan vs. no-suicide contract, the goal should be collaborative, evidence-informed planning rather than relying on a client's promise as a risk-management strategy. Put simply, a safety plan gives the client something to do, while a promise leaves them without a plan when their risk increases.
What should therapists know about documenting suicide risk assessment?
Documenting suicide risk assessment is another important part of working with suicidal clients.
Documentation should reflect the assessment you actually completed and the clinical reasoning behind your decisions. Depending on the situation and your practice setting, this may include relevant suicidal thoughts and behaviors, risk and protective factors, access to lethal means, interventions provided, consultation, disposition decisions, and the safety plan for suicidal ideation you developed or reviewed. It should also include any relevant responses from the client that indicate how they received the information and education.
When documenting suicide risk assessment, avoid treating the note as simply another box to check. Your documentation should help another qualified clinician understand what you assessed, what you determined, and why you chose the intervention or level of care you did.
Clinicians should also follow applicable laws, licensing requirements, organizational policies, and professional standards for their setting.
Why is collaborative crisis intervention planning important?
Good crisis intervention planning isn't about predicting with certainty what a client will do.
It's about preparing for the possibility that their level of distress may change.
That's why I prefer to think about a safety plan for suicidal ideation as a living clinical tool rather than a one-time document. Review it. Update it. Ask whether the coping strategy that sounded good three months ago actually worked. Find out whether the person listed as a support is still someone the client would call.
The Stanley-Brown safety planning intervention gives us the framework, but collaboration is what makes the plan usable.
Ultimately, the best safety plan is not necessarily the most detailed one. It's the one the client can find, understand, and actually follow when they need it most.
Sources
Boudreaux, E. D., Larkin, C., Vallejo Sefair, A., Ma, Y., Li, Y. F., et al. (2023). Effect of an emergency department process improvement package on suicide prevention: The ED-SAFE 2 cluster randomized clinical trial. JAMA Psychiatry.
The Columbia Lighthouse Project. (n.d.). About the Columbia-Suicide Severity Rating Scale (C-SSRS).
Doupnik, S. K., Rudd, B., Schmutte, T., Worsley, D., Bowden, C. F., et al. (2020). Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: A systematic review and meta-analysis. JAMA Psychiatry.
Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., et al. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry.
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