79

Chapter 9
Safety Planning and Lethal Means
Counseling with Youth

Maureen F. Monahan and Barbara Stanley

There is a growing body of research to suggest that most suicidal crises (i.e., the
period of time in which someone seriously contemplates killing themselves) are
relatively brief. Close to 50% of youth aged 11–15 who died by suicide had no evi-
dence of pre-planning (Holland et al., 2017), and 24% of those aged 13–34 made a
near lethal attempt after 5 min of deliberation (Simon et al., 2001). Given that many
youth contemplate suicide for a short period of time, targeted interventions during
these periods may avert suicide attempts. In particular, having limited access to
lethal means and effective methods of distracting from suicidal thoughts and urges
play a key role in youth suicide prevention.

One way to thwart suicidal behaviors and allow suicidal crises to dissipate is
through the use of a safety plan (SP; Stanley & Brown, 2012; Stanley et al., 2018).
SPs are individualized lists of factors that indicate heightened risk of suicide (i.e.,
warning signs) and ways to prevent the person from engaging in suicidal behaviors.
These plans are tailored to individuals at risk and highlight their preferred internal
coping strategies, external distractors (i.e., persons and social settings), and contact
information for supportive family members, friends, and mental health profession-
als that can assist during a crisis. Arguably, the most critical component of an SP is
lethal means counseling (LMC), the final step in the Stanley-Brown Safety Planning
Intervention (Stanley & Brown, 2012), which has been adopted in many healthcare
and community settings. LMC involves working directly with individuals at risk for
suicide to limit access to lethal methods (e.g., locking pills in a cabinet) until the
risk of suicide has diminished substantially. LMC may be especially important for
youth living in homes where firearms are present. Studies have documented that
youth who live in homes with firearms have up to a fivefold increased risk of

M. F. Monahan (*) · B. Stanley
New York State Psychiatric Institute, New York, NY, USA

Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
e-mail: [email protected]; [email protected]

© The Author(s) 2022
J. P. Ackerman, L. M. Horowitz (eds.), Youth Suicide Prevention
and Intervention, SpringerBriefs in Psychology,
https://doi.org/10.1007/978-3-031-06127-1_9

80

suicide, even if they are not the owner of the firearm (for a review see Barber &
Miller, 2014). This risk can diminish by 30–50% when firearm access is limited
(e.g., temporary removal of firearms from the home, utilizing gun locks), and
research suggests limiting access to other lethal means can help further decrease the
overall risk of suicide (Barber & Miller, 2014). Thus, LMC in addition to safety
planning can have a profound impact on preventing youth suicide.

Safety Planning/Lethal Means Counseling with Youth

An important distinction between youth- and adult-focused suicide-specific treat-
ments (D’Anci et  al., 2019) is the emphasis on family involvement, particularly
through providing psychoeducation and enhancing family communication and con-
nection. Promising youth treatments that incorporate families include As Safe as
Possible (ASAP; Kennard et al., 2018), Cognitive-Behavioral Therapy for Suicide
Prevention (CBT-SP; Stanley et  al., 2009), the Treatment of Adolescent Suicide
Attempters (TASA; Brent et  al., 2009), the SAFETY Program (Asarnow et  al.,
2017), and a specialized emergency room (ER) care intervention (Rotheram-Borus
et al., 2000). Family support is a critical component of many successful youth inter-
ventions and is also used in the current stand-alone SP interventions for this
age group.

Previous work suggests that lethal means interventions that emphasize psycho-
education for parents can significantly increase the likelihood of limiting their
child’s access to household lethal means (Barber & Miller, 2014). More recent stud-
ies have documented positive relationships between SP interventions that involve
families and increased outpatient treatment adherence (Asarnow et al., 2011), SP
use and means safety behaviors (Hill et al., 2020), and self-efficacy in implementing
coping strategies to refrain from suicidal behavior (Czyz et al., 2019). As such, fam-
ily involvement is likely an important component of youth SP/LMC. Clinical con-
siderations for incorporating families in treatment, as well as other recommendations
for engaging in SP/LMC with youth, are discussed below.

Important Considerations for SP/LMC with Youth Clients

Developing an SP with youth clients should always involve a caregiver, either dur-
ing the development of the plan or after the plan has been created. In either case,
caregivers should be provided with copies of their child’s SP. This collaboration can
increase caregiver self-efficacy in helping youth manage crises and identifying
when immediate, emergency care is needed. With caregiver involvement playing a
significant role in maintaining safety over time, it is equally as important that youth
consent/assent is obtained, and youth are made aware their SP will be shared with

M. F. Monahan and B. Stanley

81

their caregivers. Safety planning is built on a foundation of trust between the client
and mental health provider. Failing to disclose parent involvement and limitations
of confidentiality generally could be perceived as a betrayal of trust with negative
implications for treatment adherence and outcomes.

The next set of recommendations relate to the school environment. Similar to
working with caregivers, providers should strongly consider communicating with
the youth’s school regarding their SP and make note of any special accommodations
that may be warranted (e.g., unrestricted access to guidance counselors, permission
to step out of classroom to use coping skills when highly distressed). Providers
should obtain youth consent/assent, make youth clients aware of what will be dis-
cussed with the school, and carefully follow each school’s unique consenting proce-
dures. Another important consideration is that youth may have different internal
coping strategies at school versus at home or outside of school, based on availability
of resources and the degree to which each skill can be used covertly (Hill et al.,
2020;  e.g., deep breathing versus singing aloud versus taking a cold shower).
Providers and youth clients may want to develop separate SPs for home and school
or create distinct categories for each setting in one comprehensive SP.

It is also important to be aware of how youth’s developmental stage may differ-
entially impact the safety planning process. Most youth do not initiate therapy on
their own (Stiffman et al., 2004) and may feel a lack of autonomy related to being
in treatment in the first place. Without initial buy-in, youth may be less likely to
fully engage in therapy, which could negatively impact their likelihood of develop-
ing a meaningful SP or disclosing thoughts of suicide. Developmental consider-
ations are especially relevant with respect to counseling on lethal means. SPs should
be developed as collaboratively as possible so that the youth feel empowered to
have an active role in creating a safe environment rather than restricted. If approached
in a prescriptive or rigid manner, clients can interpret a discussion on limiting their
access to lethal means as a violation of their rights or a form of punishment. Mental
health providers may decide to devote extra time toward reframing this process as a
way for the individual to help keep themselves safe, as opposed to a way to restrict
their independence.

Fostering the youth’s autonomy in this process should be carefully balanced with
the overarching goal of keeping them safe. This balance may be more salient when
generating lists of internal coping strategies and external supports (Hill et al., 2020).
When compared to adults, youth may have less life experience and often a smaller
repertoire of coping skills. Thus, providers may have to offer a range of suggestions
and teach adaptive coping strategies that will be effective in a time of crisis. In addi-
tion, providers should keep in mind the changing peer relationships and perceptions
of closeness inherent in adolescence (Marsh et al., 2006). Only adult contacts should
be listed as people the youth can turn to for help in a crisis. Trusted peers may only
be listed as people who can help distract them from suicidal thoughts.

Finally, given the facility youth have with electronic media and its ubiquity, pro-
viders should consider utilizing mHealth (mobile health) applications, such as the
Stanley-Brown Safety Plan© app (Two Penguins Studios LLC, 2013) or the MY3

9 Safety Planning and Lethal Means Counseling with Youth

82

app (Mental Health Association of New York City Inc, 2013), in addition to paper
copies of the SP. An added benefit of mobile applications is that they are more read-
ily accessible through the youth’s phone, as opposed to a paper version which may
be more inconvenient or susceptible to being misplaced. It is important to note that
these recommendations for youth SP are largely based on clinical judgment and
experience as opposed to specific empirical findings. There is a pressing need for
research to address the gaps in youth SP.

Future Directions for Research and Policy

Some gaps are methodological and others technological. There is a striking need for
studies with rigorous designs (e.g., longitudinal, randomized controlled trials) to
assess the effect of youth SP/LMC on key outcomes (e.g., suicidal ideation, attempts,
suicides). Along these same lines, future work should investigate the active ele-
ments of SP on treatment outcomes to generate a clearer picture of which steps are
critical for preventing youth suicide. The field would also benefit from greater
development and testing of mHealth or web-based SP interventions for youth. Areas
for further study include mobile app push notifications that prompt users to practice
coping strategies and reinforcement after successful SP app use to increase the like-
lihood of using SP strategies in the future. Studying how mobile technologies can
increase SP/LMC use is especially relevant in light of the world’s growing reliance
on technology.

While continued research in these areas is important, SP/LMC practices must
also be adopted in real-world settings to effect meaningful change. We are high-
lighting a call to action to allocate more funding, training, and resources for large-
scale implementation and dissemination of SP/LMC across youth educational
institutions. Training more school counselors in these brief and effective interven-
tions could have a major impact on youth suicide. Unfortunately, youth at risk often
do not get referred for specialized care as suicide risk is complex and sometimes
difficult to recognize. Therefore, this initiative would be most effective if, in addi-
tion to training school counselors in SP/LMC, training in suicide risk screening was
broadly disseminated to school staff and community members (e.g., teachers,
administrators, coaches, mentors, etc.). These parallel initiatives could facilitate
more referrals to school counselors trained in SP/LMC in the hopes of reducing
youth suicide.

Lastly, attention should be paid to care transitions. Youth are at a significantly
heightened risk of suicide when transitioning between levels of care (e.g., inpatient
unit to outpatient treatment; Fontanella et al., 2020). While SPs can aid in reducing
risk during this time, more research and policy work should focus on how health-
care and education systems can work together to make care transitions as safe and
seamless as possible.

M. F. Monahan and B. Stanley

83

Conclusion

Research has identified how limiting access to lethal means greatly reduces suicide
among adults, yet there is much to learn about SP/LMC with youth clients. Based
on what is known regarding current best practices, providers should center SP adap-
tations around family involvement and strongly consider working with youths’
schools to maximize SP efficacy. Providers must also pay careful attention to issues
of consent and confidentiality, ensuring that youth are aware of what information
will be shared and with whom. Further, providers may decide to devote extra time
toward generating buy-in and maintaining a collaborative stance throughout the SP/
LMC process. Policy work should focus on care transitions, implementation of SP/
LMC in schools, broad dissemination of suicide risk screening in communities, and
technological advancement of SP/LMC.

Acknowledgments Research reported in this manuscript was supported by the National Institute
of Mental Health of the National Institutes of Health under award numbers R01MH112139 (PI:
Stanley) and R01MH109326 (PI: Stanley). The content is solely the responsibility of the authors
and does not necessarily represent the official views of the National Institutes of Health.

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9 Safety Planning and Lethal Means Counseling with Youth