By Larry Pruitt, Ph.D.
April 16, 2020

U.S. Air Force photo by Staff Sgt. Jonathan Snyder

In my previous blog entitled Going Virtual: Conducting High Quality Suicide Safety Planning Remotely, we discussed the steps to putting together a robust safety plan for patients at risk of suicide, whether the process is happening face-to-face or via telehealth. Here we'll discuss how to identify and modify the positive coping strategies that will be listed on those safety plans. And more specifically, what you and the patient should consider in the context of social distancing and shelter-in-place orders.

First: If your patient's safety plan was created before March 2020, now would be a great time to review and update it. The local and national changes we're all experiencing in response to COVID-19 have created a sudden, drastic societal shift that will likely affect a patient's access- and ability- to engage in certain coping strategies. For example, if an identified strategy was "meet my friend at the diner for coffee," the logistics of that obviously need to get re-worked. The function of that strategy (social connectedness, seeking support, etc.) can certainly be retained, it might just look a little different on the surface.

Second: Due to rapidly evolving recommendations, the constant cycle of news, and uncertainty about what the next few weeks might look like, it's expected that you'll see additional anxiety in many of your patients. Safety planning may be a great way to identify/name these feelings and discuss the impact they're having on the individual. It's very likely this will show up in the "triggers" section of the safety plan and it creates an opportunity to discuss the impact these current events are having on the patient's existing (and/or new) triggers.

This also broadens the applicability of safety plans from a tool that's typically used with patients who are at elevated risk of suicide, into a more general 'coping plan' tool that any patient can use to help plan for – and manage – this period of time when it's both understandable and expected that they'll experience some increase in anxiety, isolation, and withdrawal from the normal activities that help them manage negative mood, affect, and cognitions.

Third: Due to social distancing guidelines and shelter-in-place orders, patients may feel lonely and isolated. Given this, now is a great time to speak with them and get very specific about social contacts who they can – and are willing to – speak to on the phone, through social media, or via other outlets. This is also a great time to help them identify some preventative social contact strategies instead of waiting until that isolation really sets in. Maybe it's a weekly phone date with a friend, a quick chat via text daily, or putting pen to paper with an old pen-pal.

Fourth: A note about social media. Often, clinicians must discuss the dangers of social media and its impact on mental health for our patients. Many of our patients see others' curated representations of their lives and may feel badly about their own. In this way, social media can be a real problem for some patients. However, during the current COVID-19 situation, social media may help to foster connection or distraction in the absence of routine in-person contact for some patients. This requires thoughtful, individual consideration for each case. There are real, plausible benefits to virtual connections at this time. These could include Zoom get-togethers, FaceTime, picture exchanging through text, remote game playing, etc.

In addition to these new considerations, many tried-and-true coping strategies may need to be tweaked at this time. A few examples include:

• Exercise: Gyms and many public places are closed. What can the patient do to continue to be active and exercise? Can they do exercises in the home, do they have any equipment? Help them name these possibilities, and be specific.
• Seeing grandkids, or other family: Encourage patients to consider phone or virtual contact at this time, or help them think of a way to create/write/build something that they can treasure after life returns to normal.
• Going to public places: This currently won't work, but there are multiple, free online services that can be used for virtual 'get-togethers'. Zoom, FaceTime, Google Hangout are just a few. Also, many museums and art programs have virtual tours or events that are available.

Alternative strategies that also foster a connection, sense of worth, and some degree of control or action include:

• Helping someone else: While this may be less feasible under shelter-in-place orders, all of us know someone who is more at risk than others. Think creatively with your patient about how they could support others who are also struggling right now. Finding simple, safe ways to help someone else can create a much-needed sense of achievement for a patient who is feeling isolated or is struggling to see their place in the world.
• Creating a virtual or real hope box: This can be a simple, creative way for patients to remind themselves of those things that keep them going, while also providing them with a useful tool during intense emotional crises.
• Discussing the importance of keeping some kind of routine: If the individual is working from home or being asked to shelter in place, it can be very easy to spend all day in bed without getting out of your pajamas. Sticking to a stable routine that involves regular, commonplace actions can help prevent boredom and keep the patient focused on goal.

Lastly it may be helpful for patients just to acknowledge the impact that COVID-19 is having on their lives and to discuss how normal it is to have those thoughts and feelings. As one military veteran I work with said recently, "At least I know I am not the only one home alone and isolated, this is happening to everyone, so I don't feel alone in that."

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.