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Crisis Safety Plan: A Collaborative Model

Nancy Pierce, M.A. LICSW

Mental Health Center of Dane County - npierce@chorus.net

5585 Highway J

Mt. Horeb, WI 53572

Families' statements after a suicide: "I wish I had known…;" "If only someone had involved me…;" demonstrate their need to be more informed and on board during a suicidal crisis of a loved one. Crisis workers need to work with the families of suicidal clients as well as with the clients themselves. If crisis units have a workplace philosophy that recognizes and supports that not all suicidal people need to be placed in an inpatient facility, then a crisis safety plan involving family or friends can be developed as a viable, even preferred, option. Crisis workers need to learn how to develop, implement, and monitor the effectiveness of a collaborative crisis safety plan with families and friends who are caring for a suicidal person in the community.

Hospitalization is not always an option during a mental health crisis. The client may be cooperative and wanting to remain in the community; refusing or being refused admission, with no grounds for involuntary hospitalization; chronically at risk or symptomatic; with no insurance/funding; and with a clinical history or current treatment contraindicating hospitalization. A crisis unit trained in crisis safety planning can collaborate with the clients' family/friends and community supports and can partner with involved law enforcement, to maintain crisis clients in the community.

When hospitalization is not an option during a mental health crisis, mental health units tend to spend most of their time assessing suicide risk and setting up a disposition. Clinicians spend less time and energy teaching family and friends how to monitor and provide crisis care and instead assume family/friends know how to care for their loved ones who are suicidal. Crisis units need to provide information, support and direction to family and friends as well as be accessible and responsive to those involved in crisis safety plans.

Developing a crisis safety plan starts with identifying who can support and monitor the client in the community: primary supports (family and friends); secondary supports (extended family, advocates, co-workers, church, community); and, professional supports. Crisis workers need to learn about the family's/friend's culture and belief systems in regards to mental illness, suicide, AODA, mental health treatment including medications, as well as their relationship with the identified client. Crisis needs to confirm that the community placement is weapon-free and has an accessible phone to call for help.

Family and friends should not be primary supports in a crisis safety plan if there is current/active dangerousness, mental illness, AODA, violence, or abuse (past or present). Support persons who are too anxious, exhausted, blaming, and unsupportive of the client and the treatment -- should not be functioning in a primary role. Family/friends who refuse to be involved, will not cooperate with the crisis team or who don't care about the client's safety -- should be excluded. Crisis staff should meet or talk with primary support people so that a workable crisis safety plan can be designed to fit the unique needs of the client.

Crisis staff should keep the safety plan realistic and adaptable. Crisis communications should be direct and open, inviting client participation and sharing what information is relevant and necessary to know in order to ensure the safety of the client. Remind family that suicidal crises are time-limited, that professional support will be available and that the hospital is always an option. Dispel commons myths about suicide by giving accurate information. Remind family/friends that if the client is in immediate danger, the police are the emergency responders to be called for transport to a safe and secure place.

Crisis staff should be prepared, if needed, to teach the family "how to" manage dangerousness and mental illness by: monitoring and checking in; being present and accessible; joining or sharing activities; and modeling "life's motions." Ground or house rules need to be established regarding medication dispensing, sleeping arrangements, and reporting comings and goings. Family and friends should be encouraged to: use open-ended questions; set short-term attainable goals; negotiate and re-negotiate safety contracts to give the clear message to the client not to kill him or her self; but, do not totally rely on safety contracts for safety. A crisis safety plan that is not working needs to be reported to crisis staff so they can make modifications and adjustments.

Clinicians need to be accessible to client/family/friends in order to schedule follow-up crisis contacts, and to check on risk, mental illness and the ongoing workability of the plan. Advise family/friends to allow secondary supports to help them out so they can take needed breaks for self-care and refer the family to support groups for additional, ongoing help. All members of the crisis unit need to be apprised and involved so the clinical responsibility of safety plan is shared. Supervisory consultation and clinical documentation can serve as important in-house supports for crisis safety planning.

Crisis units need to recognize special needs groups that may need more support and structure than a basic crisis safety plan can provide. Clients with chronic suicide ideation or self-injurious behavior will need modifications in the plan with adjusted goals and expectations. Elderly persons or children, clients using drugs or alcohol, clients with severe mental illness or a disability -- will need crisis safety plans designed to address their special needs.

If the crisis safety plan is not working based on reports from the client, family/friends, community, and crisis unit -- then suicide risk, mental illness and the crisis safety plan will need to be re-assessed. Crisis units should immediately follow-up on reports that the client's suicidal risk can't be managed outside hospital or that the client or family/friends are unwilling or unable to follow the safety plan. Staff should consider all options including hospitalization and then make an appropriate disposition. If the crisis safety plan does work, staff should continue to monitor dangerousness and mental illness by reinforcing the safety plan and continuing crisis support. Crisis staff should help the client and support systems prepare to transition out of crisis mode and should develop short-term treatment plans for the client in the community. Finally, crisis staff should acknowledge the efforts and collaboration of the client, the support systems and the crisis staff in the development and implementation of the crisis safety plan in the community.

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