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Crisis Response & Safety

Crises, including intense and urgent suicidal thoughts, are largely time-limited and context-specific. With the passage of time and the mobilization of appropriate resources and safety precautions (which may on occasion include hospitalization), practitioners can assist clients to return to pre-crisis levels of functioning.

Crisis response is one component in the overall assessment and treatment plan. Developing basic competence in recognizing and effectively responding to a young person in a suicidal crisis is essential for all child and youth mental health practitioners. Crisis response strategies need to be both clinically sound as well as practically relevant to the particular treatment setting.

A helpful way of conceptualizing suicide and organizing initial responses to a person in a suicidal crisis has been developed. 51 In this model, five characteristics of suicide are identified which, taken together, provide the practitioner with the mechanisms for building rapport, understanding the nature of the suicidal crisis, and structuring the risk assessment process. These five characteristics of suicide are listed below:

  1. Suicide is viewed as an alternative, a solution to a problem or a feeling of intense emotional pain that the client feels is not resolvable by any other means.
  2. A person who is thinking about suicide is in crisis.
  3. The thinking of most suicidal clients is characterized by ambivalence, and many clients have the awareness that two feelings exist simultaneously: the wish to live versus the wish to die or escape.
  4. There is an irrational quality to suicidal thinking.
  5. Suicide is an act of communication.

A seven-stage model for effectively working through a crisis includes the following:52

  1. Assess lethality and safety needs
  2. Establish rapport and communication
  3. Identify major problems
  4. Deal with feelings and provide support
  5. Explore possible alternatives
  6. Formulate an action plan
  7. Provide follow-up

Safety planning is another important clinical tool. Safety plans should be incorporated into the overall treatment plan based on the risk assessment process. A safety plan is different from a “no-suicide contract” because it offers a vehicle for negotiating the action to be taken by the suicidal person depending on his or her level of subjective distress and suicidality. Even though “no-suicide contracts” are often used in clinical practice, there is no evidence to support their efficacy as a deterrent to suicidal behaviour. Some of the specific limitations of no-suicide contracts are summarized below: 53 54

  • lack of evidence to support their use as a deterrent to client suicide or self-harm
  • provides no guarantee of safety
  • not a legal document
  • may provide false reassurance
  • may lower clinician vigilance
  • may be an attempt to replace a thorough suicide risk assessment

Safety planning, a proactive and collaborative process which actively involves the client, is recommended. The primary purpose is to create a plan that the youth will utilize during times of suicidal crisis, rather than providing the clinician with a sense of reassurance. Practitioners need to work with the client to ensure that they will feel comfortable carrying out whatever plan is negotiated. When developing safety plans with youth at potential risk for suicide, the following principles are important to keep in mind:

  • Collaborative in spirit
  • Proactive, i.e. explicitly anticipates a future suicidal crisis
  • Individually tailored
  • Oriented towards a no-harm decision
  • Capitalize on existing social support
  • Limits to confidentiality are made explicit
  • Time limited
  • Sources of 24 hour back-up identified
  • Document contingencies and decisions
  • Dynamic and evolving

Here is one example of a safety plan:55

When I am feeling overwhelmed and thinking about suicide, I’ll take the following steps:

  1. Take a deep breath and try to identify what’s troubling me right now.
  2. Write down all of the feelings (sad, mad, lonely, helpless, scared, etc.) as a record for later.
  3. Try and do things that help me feel better for at least 30 minutes (e.g. have a bath, phone a friend, walk the dog, listen to music).
  4. Write down individual negative thoughts and provide an alternative response that changes the perspective.
  5. If suicidal thoughts continue, I will call my emergency contact person who is…… at ……….
  6. If that person is not available, I will call the 24-hour crisis line at……… or the 1 800 SUICIDE line.
  7. If I still feel suicidal and out-of-control, I will go to the nearest hospital emergency department.