Safety Plan for a 15-Year-Old Girl with Self-Injurious Behavior and Suicidal Ideation
This adolescent requires immediate mental health evaluation today—either through psychiatric hospitalization, emergency department transfer, or same-day mental health professional appointment—with continuous 1:1 observation maintained until psychiatric evaluation occurs. 1
Immediate Risk Assessment and Action
Determine transport method based on specific risk factors:
Call 911 immediately if the patient has active suicidal intent with specific plan and access to lethal means, persistent desire to die with inability to engage in safety planning, recent high-lethality attempt, severe hopelessness combined with psychotic symptoms, severe agitation or behavioral dyscontrol, or the relative is unable to provide adequate supervision. 1
Alternative immediate evaluation (family transport to ED or same-day mental health appointment) may be appropriate only if the patient has suicidal ideation without immediate intent to act, the relative is responsive and willing to provide continuous 1:1 observation, and no psychotic symptoms or severe agitation are present. 1
Critical Actions While Patient Remains in Your Care
Maintain continuous 1:1 observation regardless of which transport method you choose. 1 This means the patient should never be left alone, even for a moment.
Remove all potential means of harm from the environment:
- Search the patient and her belongings for potential weapons, sharps, medications, or other means of self-harm. 1
- Remove access to medical equipment, sharps, medications from the examination room. 1
- Keep the patient in a safe environment until transport or psychiatric evaluation occurs. 1
Mandatory Safety Interventions with the Relative
Explicitly instruct the relative to implement means restriction immediately, even if hospitalization occurs (as this applies post-discharge): 1
Remove all firearms from the home entirely—adolescents can still access locked guns, and simply having a gun in the home doubles the risk of youth suicide. 2 If the relative is reluctant to permanently remove firearms, suggest temporary relocation to another relative, friend, or local law enforcement until the patient is stabilized. 2
Lock up all medications (both prescription and over-the-counter) in a secure location with restricted access to keys. 2
Restrict access to alcohol and substances, as high rates of intoxication occur among individuals who attempt suicide. 2
Secure all knives and other potential means of self-harm. 2
Develop a Collaborative Safety Plan (Not a "No-Suicide Contract")
Do not rely on "no-suicide contracts" as they have not been proven effective in preventing suicide and provide false reassurance. 1 Instead, develop a collaborative safety plan that includes: 2, 1
- Warning signs and triggers that indicate suicidal ideation is returning
- Specific coping strategies the patient can use when distressed
- Healthy distracting activities that could suppress suicidal thoughts
- Identified social supports (specific people by name) the patient can contact
- Professional contact information with explicit instructions on how and when to access emergency services
- Means restriction plan as detailed above
Critical Pitfalls to Avoid
Do not underestimate risk based on the medical lethality of her self-injury method—intent matters more than actual lethality, and patients frequently misjudge the lethality of their attempts. 2, 1
Do not accept the relative's reassurance alone when high-risk features are present—families often underestimate risk and overestimate their supervision ability. 1
Recognize that self-injurious behavior strongly predicts suicide attempts: 40% of individuals with SIB also report suicidality, and those with both SIB and suicidal ideation are 9.6 times more likely to attempt suicide compared to those with suicidal ideation alone. 3 The presence of SIB should always trigger comprehensive suicide assessment. 3
Confidentiality and Legal Considerations
Break confidentiality with the patient's knowledge when there are significant concerns about imminent harm. 1 Explain to the patient that safety concerns override confidentiality protections. 4
Initiate psychiatric hold if criteria are met: the patient has a mental disorder and is at immediate risk of harm to herself, and involuntary hospitalization may be necessary if the patient or relative refuses voluntary transport despite meeting high-risk criteria. 2, 1
Documentation Requirements
Document the following to protect both patient safety and medicolegal interests: 1
- Specific suicidal ideation, plan, and intent
- Self-injurious behavior frequency, methods, and severity
- Mental status examination findings
- Previous suicide attempts or self-harm episodes
- Psychiatric comorbidities (depression, trauma history, substance use)
- Assessment of the relative's ability to provide supervision and support
- Means restriction counseling provided with specific instructions given
- Rationale for disposition decision
- Follow-up arrangements made
Follow-Up Mandate
Maintain contact with the patient even after referral or hospitalization—collaborative care between primary care and mental health professionals results in greater reduction of depressive symptoms. 1 Schedule follow-up within days of emergency evaluation, not weeks. 1
Recognize that the greatest risk of reattempting suicide occurs in the months after initial presentation, making ongoing follow-up essential. 4
Family-Based Treatment Considerations
Given that this patient is living with a relative, family-based interventions show the strongest evidence for reducing suicidal ideation and self-harm in adolescents. 5 The majority of efficacious interventions focus on family interactions and sources of support. 5 Recent evidence shows family-based cognitive behavioral treatment (SAFETY) reduced non-suicidal self-injury by 95% and demonstrated large improvements in depression, anxiety, and emotion dysregulation. 6
Address underlying risk factors: SIB in adolescent girls is strongly associated with traumatic experience, depression, problems with self-regulation and affect management, and parental psychiatric disease. 7 Treatment should focus on improving affect regulation, management of emotional distress, and problem-solving strategies. 7