Safeguarding and Risk Management | Safety Planning as Standard and for Escalating Risk.

Policy and Key Information

Safety planning

The scientific base for the effectiveness of risk assessment as an intervention to predict harm is weak. We cannot guarantee to keep anyone safe but we can through thoughtful practice support people to feel safer and manage their safety better.

All clients benefit from a safety plan to help them cope when their mood becomes low. Safety planning is a useful intervention in itself and can be reframed as self-care or distress management if this is more likely to gain the collaboration of the client. Safety planning, or alternatively named, is useful to end work and part of planning for further help or waits for other services.

Safety planning is for everyone and is best when it is integrated with standard practice or preparation for setbacks going forward. Typically, when people are under severe distress they struggle to think rationally and that is why they need a plan to guide them. That is why a safety plan is best completed with client routinely before distress becomes overwhelming, not lest before we start troubling work with them which might lead to them feeling temporarily unsafe.

If we become aware that a client is at risk in our public facing services, we should always safety plan and/or revisit an existing plan. Where risk could be escalating, this information may come about through a risk assessment, a mental health wellbeing assessment or something the client says or a concern for something indicated in their history.

Adjust or select the questions to fit the circumstance. Encourage client to complete plan for themselves and own it if appropriate and also to share it with those they trust.

Dealing with a crisis online or on the phone

If the person is unsafe in the moment, you will need to ask them to call an ambulance, their dad/mother and be on the phone whilst you are online etc.; is there someone at home who can join them whilst they wait; are there any telephone numbers they can call for assistance; is anyone else in danger? Do the police need to be called? Do you need to call the office, get help from a colleague whilst you are online to get police so someone else can access client file? Can you stay online with them whilst they call someone etc? Can you call someone else by phone whilst you remain online?

i. Online Therapy – Basic Safety Plan – Questions for Clients (as standard)

Preliminary questions when safety planning is standard. If you think safety planning will help resource the client in their work with you, try to introduce the safety planning conversation into the second session agenda. You may have covered some of the first questions in your initial screen, so work in the client interest to cover bases. Record in Core Net, that you have done safety planning advice (as standard) or in response to worries about coping under stress etc.

1. Nature and mood

• How will you know you are at risk of harm?
• What does your wellbeing feel like on scale of 0-10 where 10 is worst and 0 best you have felt particularly when you have felt at risk of harm.
• What are the signs?
• Who else will notice?
• What will I notice as your practitioner?
• Will you tell me? If not, what can I do to support you in letting me know?

Rate this category RED/Amber/Green where danger, caution and all fine/green.(Self awareness; how can we improve self awareness through therapy?)

2. Resourcefulness and Support

• What can you do to support yourself or what can others do in distress? (Scaling where 0-no idea and 10 lots ideas)
• Who else knows how you feel or who could you tell? (No-one= 0, who do you talk to? No one= 0 or GP, friends, staff, family)
• How supported and equipped do you feel to deal with distress? ( 0=not resourced and 10 very resourced/supported)

Rate this category RED/Amber/Green where danger, caution and all fine/green.(How can we increases connectedness and coping skills through therapy?)

3. Story of Distress and Impulsivity *

• Have you taken action you have later regretted such as harming yourself or others? (Yes/No; Yes =10)
• Have you self- harmed before or taken risks with your safety?
• Were you with others or alone?
• Home or out or with friends?
• At work, other? (0= yes and 10 none of these apply)

Rate this category RED/Amber/Green where danger, caution and green, all fine.
(How can we support client to interrupt or slow down impulsiveness through therapy?)
Moving from signs of distress and protective factors into Safety Planning for when you mood is low.

4. Safety Plan- Things to Lift Your Mood

• What lifts your mood or contains you when you are struggling?
• Relaxation, breathing, calming music, distraction, exercise, creativity, a rehearsed moment you treasure conjured up in your mind or other prepared visualised positive situations, people you love and who offer protective effect and keep you safe, things you are looking forward to.
• What applies to you?

6. Things to Distract You

• How can you distract yourself? Concentrated task, TV, films upbeat, upbeat music, creative tasks, being outside with nature, exercise, cleaning and cooking etc

7. People to Support You

• Who are they?
• What are their names and contact details?
• Who matters in my life and to whom do I matter?
• What words would they offer you that are helpful?
• Who are the professionals who can help?

You may wish to email standard safety plan to client using NHS account for security or you might request client uses your discussion to write their own safety plan and share next time? Have they noted down main headings to write their plan?

ii. Safety Planning or Revised Safety Planning as Risk Emerges

How are you feeling? 0-10 where 0 best you have been and 10 the worst

• What is troubling you most
• Where are you on wellbeing scale where 0 is best and 10 worst you have been?
• Will this pressure reduce soon/when; what else?
• Will this pressure reduce soon/when?
• Too overwhelmed to know (0)
• What’s changed or new?
• Who else has noticed? What time frame and information on the above?

Rate this category RED/Amber/Green where danger, caution and all fine.

Suicidal Thoughts

• Do you think of ending your life?
• How often and when do you have these thoughts?
• When did you notice it started?
• What has changed?
• Do you wish you weren’t here or the distress to stop or do you want to really die? (Additional if appropriate-How long do you want to die for? I wouldn’t wish to die if I knew that…)
• Have you been in social media conversations or suicide websites? (All suicide thoughts are 0-1 )

Rate this category RED/Amber/Green where danger, caution and all fine.

Hopefulness

• What are you looking forward to?
• What keeps you distracted?
• What helps you to live?
• If nothing or cannot say =0

Rate this category RED/Amber/Green where danger, caution and green, all fine.

Plan

• Have you a plan to take your life?
• Have you a method in mind?
• Have you access to means?
• Have you a place?
• All of these 0

Rate this category RED/Amber/Green where danger, caution and all fine.

Getting Through

• How are you going to get through right now/or when things are tough?
• How can you buy time for help to be accessed or what activity do you start whilst wait happens?
• Who is there with you now? Samaritans? Tel number. Other agencies?
• (What can you do? If history of previous harm, can you avoid triggers that led to acts?)
• How can you make the situation safer right now or if you have a setback?
• Is there somewhere you can go, where there is support there?
• Can you take away or lock away the source of harm?
• Can you call someone who can make you feel safer? Who and what number
• Is there something you can read, a video you can watch or a voice message that you can play to make you feel safer? Inspiring quotes, helpful thoughts and challenges or balanced statements in response to unhelpful thoughts? What applies to you?

Things to Contain You

Relaxation, breathing, calming music, distraction, exercise, creativity, a rehearsed moment you treasure conjured up in your mind or other prepared visualised positive situations, people you love and who offer protective effect and keep you safe, things you are looking forward to.

What applies to you?

Things to Distract You

Concentrated task, TV, films upbeat, upbeat music, creative tasks, being outside with nature, exercise, cleaning and cooking etc

People to Support You

• Who are they?
• What are their names and contact details?
• Who matters in my life and to whom do I matter?
• What words would they offer you that are helpful?
• Who are the professionals who can help? GP name and number, other professionals including Samaritans tel number. 111 tel numbers if they apply.
• Anything else?

Practitioner Notes

Background

Highlight these additional risk factors in any referral or notification of others:

Autism spectrum, isolation or outside area where person lives (far away from home), previous or current mental health, out of work, alienation from peers, multiple institution moves, bereavement, significant numbers of adverse childhood events, link with other, family or community suicide ,wait for service and distress, feeling no one cares or no one is helping, medical or health condition, ADHD or impulsivity, drugs or substance abuse, previous self -harm or suicide attempt, highly expressive emotional pain, adverse and recent family breakdown and conflict in family, recent row or fallout, tense or difficult relationships with others in particular…

Practitioner Actions Online Therapy

Talk to manager, use setting risk management processes.

Refer if there are any RED categories 1- 0s and mood concerns. Link with GP, primary care or timing allows and or First Response service/crisis support, A and E; Safety planning always, involve others as appropriate to prioritise safety. Consider access to means as part of plan and include access to web sites. Circle of support across contexts as longer term risk management tool.

Referral to GP Service or Emergency Services –Use Template for GP

Write in the categories (Nature and mood, above and highlight additional risks in background and any protective factors in place including steps you have taken EG – support or notification and safety planning.

Use language such as ‘passive currently and not taking action on suicidal thoughts’, beginning to take action on suicide thoughts e.g., website access to suicide sites’, ‘behaviour is getting more dangerous and struggling to distract himself from suicidal thoughts’, ‘increased frequency or distress; he struggles to work within the safety plan’; or he is working well within the safety plan’ etc.