Suicide Safety Planning During a Pandemic: The Implications of COVID‐19 on Coping with a Crisis

The rapid global spread of the novel coronavirus disease (COVID-19) from late 2019 through at least the spring of 2020 represents a significant public health crisis. The final impact on populations, health care systems, and the global economy is unlikely to be known for some time. However, what is immediately obvious is that the spread of this disease has spurred rapid and drastic changes in day-to-day life across the world. In the United States, prolonged closure of the public school system, statewide shelter-in-place orders, and guidance around social distancing represent unprecedented strategies being utilized to limit the spread of this disease. As cities, states, and nations engage in directed and purposeful isolation in order to slow the spread of COVID-19, important questions emerge regarding the collateral impact that this public health intervention may have on other diseases and health-related outcomes. In particular, the impact of social distancing on behavioral health conditions such as depression, anxiety, and the catastrophic outcomes they can produce, namely suicide, is unknown but concerning (Bentley et al., 2016; Bryan, et al., 2015; Colucci & Martin, 2007). Individuals at elevated risk for suicide may be disproportionately affected by the unintentional side effects of social distancing (Reger, Stanley, & Joiner, 2020). Given the physical isolation and social withdrawal mandated by local, state, and federal governments, the behavioral health community must work proactively to ensure that the clinical needs of patients who are at risk for suicide are skillfully adapted to these new environmental conditions and the demands of a socially distanced lifestyle. Let us be clear that this is not to argue that social distancing strategies are not critically important to the national and worldwide response to COVID-19, but rather to make the point that this strategy may very well have unintended harms. As a result, we must be agile in the strategies used to minimize that potential for harm. While many large-scale shifts are underway to ensure behavioral health services can be safely delivered during the COVID-19 crisis, such as moving to remote/virtual care (U.S. Department of Health & Human Services, 2020), it is also important to consider adaptations that are necessary to promote wellness for our socially distanced patients between sessions. One particularly prudent example centers around safety planning as a crisis response intervention and tool for individuals who are at an elevated risk for suicide. While a number of models of safety planning exist, a prominent model (Stanley & Brown, 2008) involves a written plan that identifies 1) warning signs of an impending crisis; 2) strategies for independently coping; 3) people to contact who can help distract, support, or resolve the crisis; 4) contacting mental health professionals; and 5) reducing the potential for use of lethal means to suicide. The Joint Commission has recommended safety planning with patients with suicidal ideation, and the intervention has demonstrated significant reductions in suicidal behaviors among individuals at risk. In the context of this pandemic, however, key questions emerge: Are the tried-and-true strategies for emotion regulation and behavioral activation that commonly find their way onto safety plans still possible in a socially distanced world? Is there key information that clinicians should be aware of in order to custom tailor those plans to the evolving context of each individual patient's life during a pandemic? And what can be done when long-standing, effective crisis management strategies are no longer feasible, promote risk for a separate problem (such as infection of COVID-19), or are even in direct violation of state-issued shelter-in-place orders? Behavioral health care clinicians are faced with the task of supporting at-risk patients in the context of the psychosocial stress of the COVID-19 pandemic, a time when there is very limited access to many common sources of coping and support. Given this, we encourage providers to review the safety plans that they have previously developed with their patients and determine whether any of the coping strategies identified need to be adapted to accommodate social distancing strategies for managing the spread of the COVID-19 illness. Next, we identify some common strategies that may no longer be feasible under current shelter-in-place orders that are being issued in most communities, as well as some ways in which to alter strategies so that the core function of that behavior (e.g., social connectedness) is retained, even if the actual behavior is different. We also discuss how the use of technology may facilitate virtual socializing and some alternative strategies for building a sense of meaning, purpose, and mastery during times when one may be severely limited in terms of basic activities of daily life. While some research exists suggesting that large-scale natural and national crises are not associated with population-level changes in the rate of suicide-related behavior (Dynes, 2003; Sweet, 1998), other research has shown that that risk factors associated with suicide can be increased significantly (Galea et al., 2002; Stein et al., 2004). Indeed, Kessler (2007), in a study of Hurricane Katrina survivors, found that even though a doubling in the prevalence of serious mental illness was observed after Hurricane Katrina, the rate of suicidality was unexpectedly low. The role of posttraumatic personal growth is cited as having a potentially ameliorating effect. Given this, it is unclear what direction the trajectory of suicide across the population will flow. It is possible that a national sense of commonality and unity has emerged, such that belongingness is increased and risk of suicide is decreased. That said, the drastic changes that are being put in place to minimize COVID-19 transmission, including social distancing, travel restrictions, and disruption in routine, may either directly exacerbate suicide risk or indirectly increase risk by contributing to outcomes such as financial strain, work-related stress, childcare challenges, interpersonal struggles, and other negative outcomes that have been shown to contribute to suicide risk (Denney, Rogers, Krueger, & Wadsworth, 2009; Reger, Stanley, & Joiner, 2020; Snipes, Cunha, & Hemley, 2012). Clinicians should expect and prepare for an increase in the number of individuals they are currently treating who might benefit from a safety plan. Furthermore, it is interesting to consider the potential role of adapting common suicide safety planning strategies to support the coping of those who are not experiencing suicidal thoughts. These individuals may benefit from an adaptation of this intervention to facilitate proactive discussions about how to maintain individual wellness during unexpected crises or periods of elevated stress. Thus, it may be prudent to broaden the clinical scenarios for which safety planning may be beneficial. Shifting the conceptualization to a more general coping plan may add greater applicability and value toward identifying positive coping skills and strategies to avoid the exacerbation of mental health struggles that prolonged isolation may foment (Durkheim, 1897/1951; Durkheim, 1997; Williams, 2007; Wray et al., 2011). The mental health side effects of measures to reduce COVID-19 spread are unknown but likely include anxiety related to risk of infection and the uncertainty associated with the duration of social distancing (Reger, Stanley, & Joiner, 2020). Among those at risk, such fears can contribute to overwhelming fear, disproportionate anxiety, or perceived impending doom and we must consider the possibility that these pandemic-related thoughts and emotions could present a unique trigger for suicidal thinking. Additionally, rapidly changing guidance, the constant cycle of news, and the uncertainty about the long-term impact of COVID-19 may also result in increased suicidal thinking for some. We may benefit patients by planning strategies for how to manage those triggers and by allowing the client space to identify those difficult emotions and the impact they are having on them. When working to identify triggers that may be affecting an individual, it is important to be specific in order to facilitate actionable coping. Overly general triggers such as “Coronavirus” or "Pandemic" are unlikely to yield a clear direction or strategy for coping. Coping strategies are behaviors designed to increase emotion regulation, and produce soothing, distraction, or positive emotional experiences. They often involve reflecting on positive memories or feelings or engaging in behavioral activation. A tenet of behavioral activation is engagement in one's community or in activities that produce naturalistic reinforcement of adaptive, functional behavior (Lejuez et al., 2010). Many common coping strategies are not viable in a socially distanced community. Table 1 provides list of some common coping strategies and how they can be modified to retain their function even if the behavior is different. participate in virtual events such as: There is also value in maintaining a routine as best as possible during this time. Encouraging patients to schedule their day helps to break up monotony, and requires basic behavioral activation to get up at a specific time, bathe, get dressed, make the bed, prepare a meal, etc. Proactive suicide safety planning typically includes detailing avenues for making social contact and reaching out to trusted individuals for support. Currently, individuals may feel lonely or distanced from their social networks. Those with underlying mental health conditions may be prone to increased loneliness and isolation, and research suggests that isolation is often a contributing factor to suicidal thoughts (Durkheim, 1897/1951; DurkHeim, 1997; Lykes & Kemmelmeier, 2014). At the same time, access to regular medical and mental health care is strained, and it may become increasingly important to rely on one's social network. (Reger, Stanley, & Joiner, 2020) while health care systems transition to more routine use of telehealth. Speaking early and often with patients about ensuring that multiple, reliable, and healthy social contacts are identified in their safety plan will be beneficial alongside planning for how that contact will occur (via phone, video sharing applications, social media, etc.). It is also important to frame this social contact as preventive, in nature, rather than using it only as a reactive strategy after a crisis has erupted. Concrete planning may include things such as regularly scheduled phone calls with a friend, daily text messages to a family member living in another town, or calling grandchildren or grandparents with videoconferencing applications. The maintenance of strong social relationships despite social distancing raises natural questions about the use of social media. Often, clinicians must discuss the dangers of social media and its impact on the wellness of our clients. Many clients may see the curated representations of another's ideal life and feel badly about their own. Furthermore, there are maladaptive suicide/self-harm social media groups that may increase risk (Barnes et al., in press). In this way, social media can be a substantial trigger and problem for individuals (Appel, Gerlach, & Crusius, 2016; Liu & Baumeister, 2016; Meier, Reinecke, & Meltzer, 2016). However, it is also possible that the calculus of those reactions has changed and there may be helpful ways that social media can foster connections, right now, in the absence of in-person contact (Gonzales & Hancock, 2011). For example, the individual experience of social isolation as a communal experience and a sense of “doing your part and staying home” may actually foster a sense of belonging. Though, as with all things, moderation is often key, and it is unlikely that constant consumption of social media while isolated at home will be adaptive. Unique challenges may exist in rural areas with underdeveloped infrastructure, limited Internet access, or limited economic opportunities. Even in urban populations, some segments of the population, such as older adults, continue to cite technology as one of the most frustrating experiences they have to manage. While some basic training can often yield equivalent ability to utilize technology-based tools (Greenwald, et al., 2018; Hildebrand et al., 2004), it is wise to consider the limitations an individual may face, given that so much social connection now happens virtually. If an individual is not comfortable with technology, learning to use online videoconferencing may be more stressful than the benefit the social connection offers. Therefore, consider exploring all options for social connection including traditional phone calls, letter writing, shared experiences such as reading and discussing the same book as a friend, or having a tech-savvy friend set up a virtual museum or national park tour that both can view separately. Consideration of typical social activities can inspire creative thinking about virtual participation in similar activities. If all else fails, and a crisis results, be sure that the emergency measures section of an individual’s safety/coping plan reflects how emergency services can be accessed most effectively during this pandemic. Health care facilities are making unprecedented preparations to care for COVID-19 patients, which may involve decreasing access to some services in order to have resources available for more intensive medical needs. For hard-hit areas, this may have a significant impact on what services are available. It is important to consider what health care resources are closest and are providing ongoing behavioral health crisis services. If emergency services are contacted, what alterations in available services might be anticipated? Now, perhaps more than ever before, is an important time to discuss lethal means safety. There is a well-establish link between firearms and suicides in the United States, where fifty percent of suicide deaths are due to firearms, and the greatest portion of firearms deaths, nationally, are suicides (Anglemyer et al., 2014; Kellermann et al., 1992; Miller & Hemenway, 1999; Wiebe, 2003). Working to ensure a safe home environment can have a particularly significant effect on extending the time between the onset of a crisis and one's ability to initiate self-directed violence. Unfortunately, the opposite is also true; an unsafe home environment may become even more unsafe if an individual with high risk is isolated for an extended period of time, during a season of high stress and uncertainty, and in an environment without lethal means safety. Furthermore, during this period where shelter-in-place orders are in effect, the opportunities for interruption of a suicidal crisis are diminished. Clinicians should reassess whether an individual owns a firearm, and how it is secured and stored. It is important to consider what steps that can be taken to improve firearm safety with individual patients. Firearm purchases have been on the rise during the pandemic, and clinicians should assess whether patients have recently obtained new firearms or additional ammunition in response to concerns about changes in society (Reger, Stanley, & Joiner, 2020). It is important to assess whether an individual's firearms are unloaded, with ammunition stored and locked separately from the firearm and encourage individuals to utilize gun safes, trigger locks, cable locks, or other safe storage devices. Individuals with young children at home need to ensure firearms are fully secured to avoid accidental injuries that could result if a bored child, who is isolated at home, starts exploring their environment and identifies places where firearms are kept. The same steps toward safety can be taken with many forms of lethal means. Restricting access and barriers to those means can buy essential time for crises to abate. Medications, as a form of lethal means, raise special concerns during social distancing. Current guidance from the Centers for Disease Control is that an individual should obtain extra, necessary medications to have on hand during shelter-in-place orders (U.S. Centers for Disease Control, 2020). This may be a significant increase in the means available in an individual’s home. Clinicians should talk with patients for whom having a shorter supply of medication is preferable in terms of lethal means safety. Alternative services, such as more frequent mail delivery of smaller supplies or locked storage and distribution by a loved one, could be used to have less medication on hand while also reducing the need to go to the pharmacy in-person. Social distancing or not, these critical components guide the plan's development and allow for strategies that meet the needs of the patient’s context. In light of the unique challenges to safety planning during social distancing and with an eye toward universally relevant safety planning concepts, a hope would be that the field would emerge as better suicide safety planners, even long after this pandemic has concluded.