By Larry Pruitt, Ph.D.
April 15, 2020

DOD photo

In response to the current COVID-19 public health crisis, many clinicians are suspending face-to-face care and moving to remote care, via phone or videoconferencing. This can be a big departure from how many clinicians are accustomed to delivering care. It may feel particularly daunting to virtually treat a patient who's experiencing thoughts of suicide or has been determined to be at an elevated risk for suicide. However, when the elements of a good safety plan are closely examined, I argue there's nothing that would prevent them from being completed remotely. Remember, a good safety plan is a good safety plan regardless of whether it is constructed face-to-face or remotely.

A good safety plan is determined by a number of factors, and each of these factors can be achieved regardless of whether you're developing the plan with a patient in-person or remotely. First, consider what makes any plan work? Effective plans have certain characteristics. These include:

• Desire
• Accessibility
• Simplicity
• Flexibility
• Ownership
• Knowledge of when to implement the plan

Let's look at each one individually with remote safety planning in mind.

Desire (for the plan to work): This is crucial. Many patients at elevated risk of suicide might have some ambivalence about maintaining safety. However, if someone has a lot of ambivalence about continuing to stay alive, the best first step is to take the time to foster hope, develop and explore reasons for living, and help them access an urgent or emergent assessment and possible hospitalization to ensure safety, if needed.

Accessibility: To follow a plan, it helps to have it readily accessible and to refer to it early and often. This can be a risk of safety planning remotely because if you have to send a copy of the plan via mail, there can be a 2-3 day delay before the client receives it. One option to consider is you and the patient writing out the plan on both sides of the phone or camera, or have the patient take a screen shot of the plan when you are done. Even if the patient's version is an abbreviated plan with just one or two rock solid items for each step, it will be helpful while the full copy you drafted is in the mail. If you haven't moved completely to virtual care yet, you can plan ahead and provide any client who's moving to remote care with a couple of blank copies during their last in-person session so they have the forms available when needed. Secure messaging services provide an additional option where the completed plan could be sent immediately.

Simplicity: A plan that's easy to follow is more likely to be implemented. n fact, rather than printing out a finalized, templated safety plan as it would look in the patient's medical record, consider printing out a blank pen and paper version of the safety plan, which has all of the core components listed, add the items discussed by hand in clear legible writing (or have the patient do so), and use that copy instead. Often, the printout of a template from an electronic health record contains a lot of extraneous information, uses very small font, and may be several pages — making it not well suited to mailing. The pen and paper version can usually be kept to one page in large font which makes it much easier to follow during an emotional crisis. You can even consider an additional index card version so the plan can fit in a wallet or purse and be carried with the patient.

Flexibility: Plans that can be followed in a variety of situations, and that account for a range of potential barriers, are more likely to be effective. This will be especially useful in the rapidly changing context of COVID-19. However, understand that adding flexibility can make for a longer (more complicated) plan. Be prepared for this and make your clinical decisions based on what will create the best outcome for the individual. It is possible to help patients formulate flexible, yet simple, plans without adding a lot of content. The trick is helping the patient question whether the warning sign(s) or written strategy can be used regardless of the time or the day. For instance, if a patient gives an internal coping strategy of "ordering a special meal from my favorite restaurant", have them assess whether their favorite restaurant is open 24/7, and whether they'd actually place an order if they are in crisis at 3 a.m. This allows the patient to revise strategies to be more flexible.

Ownership: People are more likely to follow a plan they created for themselves than one someone created for them. With safety planning, the patient should drive, while the clinician rides in the passenger's seat and points out potholes. Ownership isn't necessarily hampered by doing the intervention remotely. The key is to be as collaborative as possible. Having the patient take the lead in writing out their own safety plan, and sharing it back with the clinician can build that sense of ownership.

Clear understanding of when to implement the plan: The number one reason patients cite for not following their safety plan is memory related. In a crisis, memory is clearly impacted and they typically either forget they created a plan, or they forget the warning signs that serve as cues to access or implement the plan. For many, those warning signs (the cues that it's time to pull out and follow the safety plan), are written on the actual plan! When conducting safety planning remotely, be sure to attend to the client's awareness of their warning signs, and take the opportunity to have them demonstrate the ability to recall their triggers from memory. Two other barriers to knowing when to implement the plan are worth mentioning:

1. Be wary of including warning signs that are present at baseline (e.g., "drinking" for someone who drinks alcohol daily, or "feeling sad" in someone who's actively depressed).
2. If a patient identifies an external event as a warning sign (e.g., "argument with my wife") try to focus on the internal reaction to that event (e.g., "hinking that my marriage is over"). External events don't tend to be very specific or helpful, instead, try to elicit more actionable warning signs.

Final thought:

Thorough safety planning has been shown to decrease suicidal behavior by as much as 50 percent (providing that the plan is personally relevant and crafted collaboratively). However, safety plans that are not individualized have not been shown to have any effect on future suicidal behavior at all. By focusing on ways to make the plan accessible, simple, flexible, ensuring the client takes ownership of the plan, and identifying relevant warning signs that they will remember, safety planning can be conducted remotely. You can find more technical guidance about the use of telehealth technology in this article.

Dr. Pruitt is a licensed clinical psychologist. He serves as the director for suicide prevention at the VA Puget Sound Health Care System, and the lead VA suicide prevention coordinator for a four state region including Washington, Oregon, Idaho, and Alaska. Dr. Pruitt is also an associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine.