Pull In Case of Emergency
How to develop your personal safety plan when suffering from depression
Now that I am no longer in my intensive outpatient therapy program (IOP) and only two months from my first foray into active suicidal ideation, I thought it would be appropriate to do a deep dive into safety planning. Suicidal ideation is when a person experiences suicidal thoughts or has thoughts about taking their own life. A safety plan is an important tool for anyone struggling with their mental health. It is especially essential for someone who has considered ending their life.
Identify and document your triggers or warning signs that increase your risk for self-harm.
Developing a safety plan requires you to get curious about past triggers that once led to suicidal feelings or urges so that you can monitor for and recognize thinking patterns, emotions, physical sensations, behaviors, and mental images before a crisis. A variety of experiences can trigger a mental health crisis. It can be common for people who are actively suffering from trauma, depression or extreme anxiety and/or are navigating a stressful life event such as grief, terminal illness (yourself or a loved one), job loss, divorce, or prolonged stressors such as work, abuse, relationship problems, or other difficult life events.
Documenting your triggers can help you and the people around you recognize when it is time to take action. My warning signs include:
Isolation
Feeling like a burden
Hopelessness
Unbearable pain
Inconsolable emotions
Insomnia
Loneliness
Feeling overwhelm/overburdened
Looping thoughts that do not disappear with grounding techniques
Exhaustion
Inability to self-soothe
Other suicidal risk factors to consider are:
Trauma (past or ongoing physical, sexual, or emotional)
Triggering events (stressors leading to humiliation, shame, despair, or loss)
Ideation (presence, duration, severity, frequency)
Medical health
Alcohol or substance use
Past suicidal attempts
History of self-harm (e.g., cutting)
Feeling trapped (physical, financial, emotional, social)
Purposelessness
Anger
Recklessness (engaging in risky behavior)
Significant mood changes
Categorize your thoughts, behaviors/urges into low, moderate, and high risk levels.
My IOP therapist had me develop a personal safety risk assessment when I reported experiencing active suicidal thoughts. Looking back at my early attempt at this assessment, it was pretty high level, probably because I was already in a state of fight or flight. It is important to spend time thinking about the specific thoughts, behaviors, and urges you have experienced in the past that may require supportive intervention when you experience them in the future. My chart asked me to rate these thoughts and behaviors/urges from 1-10 and list the actions most supportive for me when I experience them.
Identify internal coping strategies to implement when you experience thoughts, behaviors, or urges that fall on your safety risk scale.
My low safety risk (1-4) thoughts included isolated feelings of sadness. Elaborating on this now, it can look like thoughts of loneliness from lost friendships or changed relationships, remorse or grief from my daughter’s suicide attempt, sadness around the health of loved ones, or anxiety about the work day to come. These thoughts can lead me to become quiet and withdrawn when in the presence of others, enter a state of functional freeze (e.g., doom scrolling reddit/Instagram or binge watching Bravo, General Hospital, or Netflix), or physically withdraw from others and in my room. These low safety risk thoughts are generally responsive to internal coping strategies such as going for a walk, yoga, meditation, journaling, reading, taking a bubble bath, listening to music and cleaning or working on an art project, cooking, playing a game with my family, or playing with my dog or cat.
Identify external support that is effective, safe, and available when your internal coping strategies are ineffective.
Feelings of hopelessness or passive thoughts of going to sleep and not waking up are thoughts that bring me into a moderate risk level (5-7). This is when I have been isolating in my room for an extended period (more than 2 hours). I am experiencing looping thoughts that relate to the sadness or anxiety described above and my attempts to self-soothe were ineffective. This is usually when exercise is not an option (think late night or I am experiencing these emotions while under a tight work deadline). These emotions normally spill over into tears. If my emotions are at the lower end of the moderate scale, I may be able to exit the emotional spiral by seeking out external online resources (e.g., my Clarity app’s AI Journal or cognitive behavioral therapy journal, Self Healer’s Circle, or Dr. Kristin Neff’s Self Compassion tools, Harry Potter audiobook, sound healing meditation, tapping).
However, if I am on the higher end of the moderate scale, then I may require external support from a loved one. This is when I reach out to my husband, one of my cousins, or a trusted friend who has proven to be resourced, willing, and available to support me. This can look like a phone call in the middle of the emotional event or scheduling time for joy out of the house. This may not be easy when you are in depression given that it is easy to fall into the trap of feeling like a burden. From personal experience, it’s a good idea to think of these people in advance and maybe discuss their willingness to be that phone-a-friend, as not everyone is resourced or up for the task. Here are some helpful questions to help you identify your trusted circle:
Who in your circle brings you joy, makes you laugh, and helps you forget about your troubles?
Who makes you feel comfortable?
Is this person empathetic and resourced to listen when you share challenging emotions?
For more information on finding your support system, see my posts on Burnout and Grief.
Make your environment safe and identify the professionals or agencies you can contact when you are in crisis.
Suicidal ideation can be either passive or active. Passive suicidal thoughts occur when an individual no longer has the motivation to live, but does not have a plan to take their life. These thoughts turn active when the person has a plan to end their life. As this blog post from Salt Lake Behavioral Health explains, “[a]ctive suicidal ideations sound like ‘It would be so easy to end my life by . . . .’”
I am at a high safety risk level when I am having active thoughts of ending my life. I was at a high risk level when I enrolled in my partial hospitalization program in December. Then, I experienced all of my identified warning signs at once. I also knew that if I were to end my life, it would be through taking an excessive number of prescription medication.
Before asking for help, I was isolating and feeling like the people in my life would be better off without me. I was in full panic mode with inconsolable emotions. I felt hopeless and as if life was not going to get any better because I experienced two events that were traumatic to me, the safety and health of two of my closest family members in the span of 10 months. This was sandwiched between extreme feelings of responsibility at home and work, and followed by the collapse of my social support system. I had little space between events to recover my sense of resilience. The pain was unbearable in the moment. I felt overwhelmed, overburdened, exhausted from trying to be strong and incredibly lonely. If it weren’t for the lack of an intent to act on my plan, I likely would have qualified for in-patient hospitalization.
Instead of acting on my plan, I asked for help. I told my husband, called a crisis hotline, phoned a friend, told my therapists, and stepped up my care. It is important to have a list of professionals or agencies you can call when you reach the high risk level. Ideally, you will already be under the care of a psychiatrist and therapist. If you don’t, see my past blog post on depression for resources. Keep the National Suicide & Crisis Prevention Lifeline handy. There are also local agencies you can call (e.g., DC, VA, MD, see also The Columbia Lighthouse Project and National Alliance on Mental Illness for more resources).
We installed safes to store kitchen knives, scissors, medicine, and other self-harm tools throughout our house after my daughter’s suicide attempt. For my safety, I no longer have access to these safes. I must now rely on my husband to dispense my medication or give me a knife to cook. While inconvenient, these steps are necessary to keep both my daughter and me safe.
What about you? Do you know how to recognize when you are experiencing a mental health crisis? Do you know what to do if it happens? Here is a helpful template to get you started on documenting your safety plan.
In case if you missed them, here are helpful resources I linked throughout this week’s blog:
Suicidal Ideation Definition (Yale Medicine)
Resources for supporting someone with suicidal thoughts (Samaritans.org)
Safety Plan Template (Getselfhelp.co.uk)
Suicidal Ideation Risk Assessment (Minnesota Department of Health)
Signs You’re Stuck in Functional Freeze (Health.com)
Safety Planning (Grassroots Crisis Intervention)
Suicidal Risk Factors (American Foundation for Suicide Prevention)
Difference between Passive and Active Suicidal Thoughts (Salt Lake Behavioral Health)
What a valuable post and resource. Thank you. 💗😊💗