8 Reasons Why One Strategy Is So Effective at Preventing Suicide
Empowerment, connection, openness, and more.
Posted August 9, 2022 | Reviewed by Ekua Hagan
- Safety plans have largely replaced the much less effective "contracts for safety" in therapists' efforts to keep suicidal clients safe.
- Awareness and early intervention are crucial for interrupting an impending suicidal crisis.
- Hope and connection are key factors that prevent suicide.
As therapists, we do everything we can to prevent our patients from ending their lives. Thankfully, the techniques we have now are much better than what was available a couple of decades ago when I did my initial training.
At that time, I was taught to have a patient sign a “contract for safety” if they were thinking of suicide. A typical contract stated that the patient agreed not to kill themselves before their next appointment and that they would go to the emergency room or call 911 if they were seriously considering it. If they were not willing to sign the contract, then a visit to the emergency room for a psychiatric evaluation was considered necessary, which likely would mean a stay in the psychiatric ward.
I was involved in a few safety contracts back in the day, and it seemed obvious to me that everyone knew they were a total CYA move by therapists and clinicians. After all, who was going to enforce the “contract” if the patient broke it by killing themselves? Besides being relatively ineffective, they could weaken the therapeutic bond by signaling that the clinician cared first and foremost about potential legal liability, more so than the patient’s actual safety and well-being.
Therapists now have a much better tool for saving lives. It’s called a safety plan, and research has shown that it effectively prevents suicide. A meta-analysis of 6 studies and over 3500 patients found that for every 16 people who get a safety plan, 1 suicide attempt is prevented, on average (Nuij et al., 2021). One study found that people considering suicide were nearly 4 times as likely to make a suicide attempt if they received a contract for safety versus a safety plan (Bryan et al., 2017).
Creating a safety plan is straightforward. It simply lists the warning signs of an impending suicidal crisis and things for a person to do when they’re having suicidal thoughts in order to cope with how they’re feeling and keep themselves safe. Options range from simple activities one can do on their own (e.g., going for a walk) to more intensive options like calling one’s psychiatrist or the Suicide and Crisis Lifeline (988). This information lives on a single sheet of paper that is kept easily accessible for when it’s needed. (See this template for a full description of creating a safety plan.) Safety plans highlight the therapist’s concern not just for the patient’s safety, but for their mental and emotional well-being since the plan offers ways to reduce distress.
How can such a seemingly simple technique have such a big impact on suicide attempts? Research has not fully answered this question, but these factors seem to be important:
1. Awareness of Warning Signs
Reducing suicide risk starts with knowing when a crisis is looming. Identifying these signs makes it easier to recognize when they’re present.
2. Intervening Early
Knowing the warning signs allows for interrupting the progression toward suicidal behavior relatively early in the process. As with so many things, early intervention is more effective than trying to address a problem that’s been developing for a while and has built up a lot of momentum.
Simply having a safety plan can increase hope—a crucial protective factor—by helping a person to feel that they’re “less vulnerable and less at the mercy of their suicidal thoughts,” according to Barbara Stanley and Gregory Brown, the creators of the safety plan.
4. Multiple Options
One coping method may be helpful at one time but not so helpful at another. Building multiple options into the safety plan increases the odds of finding something that works when it’s needed.
5. Tailored to the Individual
Safety plans don’t come “off the rack,” but are custom-designed for each individual. This customization ensures that the options they list are well-matched to the person.
6. Easy to Use
It’s hard to think creatively in the middle of a crisis, and the habits we fall back on might not be the most effective. Safety plans make it easy to remind ourselves of ways to cope, without having to come up with ideas in the moment since they’re already written down on the plan.
7. Encourages Openness
Some of my therapy patients have sometimes hesitated to bring up suicidal thoughts out of fear that I would reflexively call 911 and have them put in a psych ward. Safety plans underscore that having suicidal thoughts does not equal an automatic trip to the hospital and involuntary commitment. There are multiple opportunities to interrupt the process before emergency steps are taken.
8. Fostering Connection
Finally, safety plans can build connection, which is another crucial factor that protects against suicide. The plans are made collaboratively between therapist and patient—which can strengthen the therapeutic alliance—and they signal the therapist’s trust in the patient’s ability to cope. Additionally, three out of the six steps emphasize social contact, from being in public spaces like a coffee shop to contacting loved ones or mental health professionals.
Recent research shows that most therapists—roughly six out of seven—use a safety plan when their patient is thinking of dying by suicide (Moscardini et al., 2020). If you've had thoughts that maybe life isn't worth living, consider making a safety plan for yourself. If you're not currently in therapy, you might ask a trusted loved one to help you put it together.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.
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Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., Williams, S. R., ... & Rudd, M. D. (2017). Effect of crisis response planning vs. contracts for safety on suicide risk in US Army soldiers: A randomized clinical trial. Journal of Affective Disorders, 212, 64-72.
Klonsky, E. D., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8, 114-129.
Moscardini, E. H., Hill, R. M., Dodd, C. G., Do, C., Kaplow, J. B., & Tucker, R. P. (2020). Suicide safety planning: Clinician training, comfort, and safety plan utilization. International Journal of Environmental Research and Public Health, 17, 6444.
Nuij, C., van Ballegooijen, W., De Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., ... & Riper, H. (2021). Safety planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219, 419-426.
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256-264.