Synopsis: Everyone needs a safety plan. Death by suicide is usually attributable to depression, yet even people who have no depression at all are at risk of suicide at times of extreme stress and vulnerability. This article describes the nature of suicidal thoughts and how to develop a safety plan to prevent suicide.
BY LEN LANTZ, MD, author of unJoy / 6.21.20; No. 27 / 9 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post also contains affiliate links. Please click this LINK for the full disclaimer.
Why on earth would I need a safety plan?
A lot of people wonder why they would need a safety plan to prevent suicide when they don’t have depression or don’t feel suicidal. It’s true that 70% or more of suicides are related to major depression. If you have major depression, then it is clear that you should have a safety plan to prevent suicide if your depressive symptoms become severe. Suicide is a common cause of death for people of nearly all age groups, including individuals who are not depressed. Tragically, it is the second leading cause of death in youth age 10 to 24.
We know what suicide is, right? A person ending his or her own life. However, what are the thoughts that drive suicide? What could compel someone to push against and overcome their self-preservation instinct, their innate will to live?
Feeling hopeless, being financially overwhelmed, shame, guilt, memories of past trauma, loss of a loved one and loss of an important relationship are also suicide risk factors. All of these factors can lead a person toward suicide, where death becomes a kind of ultimate escape plan. Even anger can be a risk factor for suicide. Some people feel suicidal when they are at their angriest and want to get revenge, thinking, “They would be sorry if I killed myself.”
Depression is a liar
Because depression is the number one risk factor for suicide, I think it’s important to talk about what depression does to a person’s thinking. I’m going to frame suicidal thoughts in an unusual way for you so that you can see it in a different light. I know I sound weird when I say this, but I kind of think of depression as an evil force that constantly lies to people. When a person with depression is vulnerable (feeling hopeless, feeling overwhelmed or is intoxicated), they start to listen to and believe the lies of the evil force. So, what lies does depression whisper in the ears of the vulnerable?
You’ll always feel this way.
You’ll never get better.
There is nothing you can do to feel better or fix this situation.
You would be better off dead.
Other people would be better off if you were dead.
If you die by suicide, your friends and family will get over it.
All of the above thoughts are factually untrue. It is unhealthy for anyone to habitually dwell on thoughts of suicide. Chronic thoughts of suicide poison your thinking and make you vulnerable. When a person is stuck in a wave of thoughts of suicide, they believe – at least, in that moment – that dying is the most logical thing to do.
All of the lies told by depression are utter BS. They are objectively not true. Suicide is a permanent attempt to solve a temporary, fixable problem. Even the most depressed people I have met can achieve periods of improvement if they are willing to pursue available treatment and change unhealthy behaviors.
Consider this: if you die by suicide, you will double the risk of your children dying by suicide someday. If you die by suicide, you will increase the risk of suicide by 50% for your family and friends. Suicide is incredibly painful for everyone. It tears at the fabric of families, friends, schools and communities. The painful impact spreads outward like a ripple on the surface of water. By killing yourself, you hand your bucket of suffering to everyone who cares about you.
The nature of suicidal thoughts
Suicidal thoughts are different for different people. A common element for many people is that the thoughts hit them like a wave. The thoughts start at a low level, then gradually build to a peak and then eventually start to diminish. This could occur in a matter of seconds, minutes or hours.
Often amid thoughts of suicide, a person can think of death as a logical solution. That is because people develop a sort of tunnel vision in their thinking. They forget about or dismiss the consequences of their actions. They forget about their future goals. They don’t factor in the negative impact on their family or friends. When that wave of suicidal thoughts decreases and their thinking expands, they often say to themselves, “What was I thinking? I wouldn’t do that to my family or my friends! I have goals for my future.”
What is the best safety plan?
The best safety plans allow people to take action, to follow a sequence of steps (positive activities) that are under their control to stay safe until the wave of suicidal thoughts goes down. It is critical to start the positive steps at the beginning of the wave of suicidal thoughts. Once you reach the peak of the wave, it is very difficult to start the positive steps.
The best safety plan that I have found to prevent suicide is the one used in the Safety Planning Intervention, which was developed by Barbara Stanley, Ph.D. and Gregory Brown, Ph.D. I believe these doctors deserve every accolade and award in existence as countless lives have been saved by people using their safety plan. It is effective and it is free! Click HERE for a downloadable pdf of the Safety Plan from the Safety Planning Intervention.
Elements of a good safety plan
The elements of a good safety plan are as follows:
Recognize Early Warning Signs
This step is really about a person recognizing common triggers for thoughts of suicide.
When the trigger hits, people should go to the next step and start working through their plan.
Use Internal Coping Strategies
I think about this step as, whatever you are doing, do something different. If that is not working, try another activity for 3-5 minutes.
Get up and shift your activities, repeatedly if necessary, to distract yourself from your negative thoughts.
If this step is ineffective, move to the next step. If necessary, jump to step 5.
Socialize for Support and to Reduce Isolation
This step is the “don’t be alone” step. Call or text someone and open a conversation.
You could say something like, “Hey. What are you up to today? What do you have going on?”
If this step is ineffective, move to the next step. If necessary, jump to step 5.
Actively Seek Help from Family and Friends
This is the step where you are asking go-to people in your life for help.
You move past “Hey. What are you up to today?” to “I’m not doing well. I don’t feel safe. I need some help.”
If this step is ineffective, move to the next step.
Actively Seek Help from a Professional
This is the step where you call your therapist, call your doctor, call the crisis line, text the crisis text line, dial 911 or go to the ER.
Reduce Access to Lethal Means
It is completely logical to distance yourself from lethal means, such as firearms or a stash of pills, if you are at risk of suicide. The research is clear that firearm ownership increases the risk of suicide by firearm.
Let family and friends show that they care about you by hanging on to your firearms temporarily when you are at a point in life when you are struggling with your safety.
There is a smartphone app called MY3, which is free and captures most of the above steps. I like the MY3 safety planning app because it takes safety planning one step further. If you are suicidal and can’t follow any steps because you got to the peak of your thoughts of suicide incredibly fast, you can simply use the app to contact the top 3 people in your life that you should reach out to in a crisis.
A very important step of any safety plan is to review it and improve it. If it looks like your safety plan has failed, see it as an opportunity to go over it again and improve it, because for many people safety plans do work and are very helpful.
A story about a guy and his safety plan
“Mike” was a 33-year-old Army veteran and he had a pretty good life. He had developed what he thought was mild posttraumatic disorder (PTSD) from his military service until an accident last year. He was fishing on a lake with his buddy Bill when a storm blew. They were in a decent sized boat, but the waves were so choppy that it was starting to swamp smaller boats. They noticed a guy in a small boat had capsized so they went to help out. The guy was in the water and went under the surface by the time they got to him and Bill jumped in to save him. Neither of them returned to the surface.
Mike felt so horrible and guilty. He kept reliving that day and some of his traumatic experiences from military service. Within a week after the accident, he was spiraling. His PTSD was severe and he started drinking heavily. He thought he might have had some mild depression in high school, but he had really severe depression now. He reached out to the VA for help.
Mike first met with a VA therapist and she said that she might refer him to a psychiatrist for additional support. She asked him point-blank about his thoughts of suicide, and Mike replied, “Every day since that day on that lake. I just want the pain to go away.” His therapist walked through a safety plan with him and they started to fill in different steps in the plan that he thought would be helpful. Mike was blown away that anyone could actually do something about their thoughts of suicide. Before meeting the therapist, he figured the only thing he could do was wait until the feelings went away. He also liked the fact that the safety plan was his safety plan and not some cookie-cutter, useless brochure.
Mike and his therapist finished the safety plan in their first meeting. Mike agreed that they would let his mom, sister and work manager know that he was struggling with thoughts of wanting to die. This would immediately improve his support network. He also downloaded the MY3 app and added in all the elements from his safety plan into the app.
The last issue to address was lethal means. His therapist’s strong recommendation was to remove all firearms from the house. Mike was unwilling to give up his guns and have someone else hang on to them for him. He lived in town and thought it was unlikely that he would need immediate access to a firearm for self-protection. He also knew that his thoughts of suicide tended to hit him severely at most for about 5 minutes. Mike’s solution was to put multiple steps between himself and his firearms. He was able to get free trigger locks from his state’s suicide prevention coordinator and he added those to his firearms. He ensured that all of his firearms were in a gun safe and without ammunition. He put all of his ammunition in a heated garage on the other side of his property in a locked cabinet. He figured that this type of safe storage would take him at least 5 minutes to deal with all the locks and acquiring ammunition if he were suicidal.
His therapist wasn’t entirely satisfied with Mike’s solution. He was still not willing to part from his firearms at the time of their visit, but she did get Mike to agree to have his sister hang on to his firearms if his suicidal thoughts worsened or didn’t improve by the time of their follow up visit the next week.
Going deeper in addressing suicidal thoughts
I’ve heard some people say that – for them – thoughts of suicide are comforting. It alleviates their overwhelming anxiety or angst. However, for most people, it is easily argued that recurrent thoughts of suicide are unhealthy.
Habitual suicidal thinking can poison a person’s problem-solving abilities. The thought of suicide becomes the solution for everything – every bad experience, every relationship conflict, every negative emotion, every moment of self-hatred or every pet peeve.
I try to get people I work with to see recurrent thoughts of suicide as a bad habit, which can become their habitual fallback. If they can see this thinking as a bad habit, they can work on gradually improving that mental habit.
When suicidal thoughts do not resolve, it can be helpful for a person to meet with a therapist trained in Dialectical Behavior Therapy (DBT). DBT is very effective at reducing the risk of suicide. Other forms of psychotherapy can also help reduce the risk of suicide. Additionally, it can be very helpful to work with a psychiatrist to better manage your depression and anxiety, which are the most frequent contributors to suicidal thoughts.
Another strategy for addressing recurrent thoughts of suicide is to make an active decision not to end your life – ever. People who tell themselves, “Suicide is not an option for me. That option is off the table” often see transformative improvement in their depression and safety as it forces them to take the necessary steps to get better and find healthier solutions to their problems.
A safety plan is free insurance for your survival
Safety plans save lives. They are not perfect and they are not the only solution for people at risk for suicide but they are essential. Imagine actually being able to do something about thoughts of suicide and having a plan – your plan – that works. Even if you don’t have depression, there may come a time in your life where you are overwhelmed by extreme stress. You need to be prepared and there is a free solution for getting prepared. You owe it to yourself and your loved ones to prevent yourself from a desperate act due to a temporary problem. You will feel stronger and less stressed knowing that you are prepared for one of life’s most difficult challenges.
For further reading, check out:
My article “Finding Quality Psychotherapy – Moving Beyond Talk Therapy“
My article “Finding a Good Psychiatrist”
A Guide to Rational Living by Drs. Ellis and Harper (See Len’s Book Review)
Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think by Drs. Dennis, Greenberger and Padesky (See Len’s Book Review)
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