Creating a Crisis Response Plan for Patients With Suicidal Ideation and Trauma-Related Disorders

​​​​​​In part 2 of this video, Craig Bryan, PsyD, ABPP, professor of psychiatry and behavioral health, College of Medicine, Ohio State University, Columbus, Ohio, discusses creating a crisis response plan that is tailored to individuals and how these plans help patients feel more in control of their mental health. Additionally, Dr Bryan, who is also the Director of the Division of Recovery and Resilience Program and of the Suicide Prevention Program at Ohio State University, explains how clinicians can talk with patients to build trust faster and increase the efficacy of the intervention.

In the previous part 1, Psych Congress Network's Senior Digital Managing Editor, Heather Flint, interviews Dr Bryan who explores clinical signs that help diagnose a patient with post-traumatic stress disorder (PTSD), the common comorbid conditions, and suicidal indications.

Dr Bryan recently gave a session titled "Helping your patient manage suicidal ideation behavior: a crisis response plan" at Psych Congress 2021 in San Antonio, Texas.

Read the transcript:

Heather Flint: In your session, you talk about crisis response plans. Can you talk with us a little bit about describing how you work with patients to create a crisis response plan that's tailored to their treatment?

Dr Craig Bryan: Yeah. The concept of the crisis response plan has actually been around for many decades. You can see the origins in the '80s and '90s in dialectical behavior therapy and then, later on, in cognitive behavioral therapy for suicide prevention.

I think most people...Now, clinicians are more familiar with a more recent iteration of crisis response planning, which is safety planning. It's a term that I think more people are familiar with.

The idea behind the crisis response plan is that we sit down with someone who's at risk for suicide and we go through a series of steps to create, oftentimes, a hand-written plan, typically on something as small as an index card or maybe a business card, a piece of paper.

We begin by identifying that patient's warning signs. We'll talk about, "How do you know that you're getting upset. that you're feeling overwhelmed?" We talk about behaviors, thoughts, feelings, somatic experiences that might signal a crisis.

We then go through identifying personalized, self-management strategies. Things you can do on your own to distract yourself, to calm yourself down, to reduce your stress. We also talk about the person's reasons for living or for not killing themselves.

Our research has shown that's actually a really important conversation to have. It significantly reduces suicidal intent and risk immediately in the moment, as well as improving or leading to faster reductions of suicidal ideation over time.

We then identify sources of social support. Friends, family members that they can reach out to. Finally, we have crisis professional services like hotlines, mental health professionals, and then 911, other emergency services.

Flint: Do you feel that having these crisis response plans gives the patients a feeling of more control over their mental health?

Dr. Bryan:  Yeah. That's one way that they've definitely described it. When we do the research, in addition to looking at the clinical outcomes we do a lot of interviews with the patients to get their feedback. What did you like? What did you not like? How did this work? Should we change something?

What we learned early on in our research was that that was what many patients were telling us, was that it was convenient. It was practical. It was personalized to them. Many of them were saying, "It's my plan."

They were telling us, "It doesn't get rid of my stress. It doesn't necessarily get rid of depression or solve my problems in life, but I feel like now I'm not captive to those urges. I realize that I do have a choice. I can redirect myself and engage in options that maybe otherwise I would have forgotten about or dismissed out of hand."

Flint: Excellent. Do you have any final thoughts or advice for clinicians when working with patients with suicidal ideation or behavior and formulating these crisis response plans you want to share?

Dr Bryan: We're doing a lot of research on this now, but one of our hypotheses is that a critical element to increasing the effectiveness of these plans is to first do a really good what we call narrative assessment.

The narrative assessment is a patient-centered approach to suicide risk assessment. One of the classic ways that many of us, as clinicians, have been trained to do suicide risk assessments is to interview the patient.

A lot of times, now, in many settings we have forms and templates that we have to fill out for legal reasons. Sometimes, to the patient, that can be experienced as very impersonal, as cold, as robotic.

We've had patients say, "You're trying to protect yourself. You're not actually trying to help me." We have some preliminary evidence that when we shift away from the interview approach to this narrative or storytelling approach we actually get higher patient satisfaction and better empathy ratings.

We had some early indications that it actually increases the effectiveness of the plans. A big part of the trainings that we do with clinicians now, believe it or not, is reteaching them how to interview and talk with patients in this way that builds trust faster and enhances the efficacy of the intervention.

The way that we do it is we tell clinicians, "Instead of asking questions, open up with a different kind of question, which is just, 'Would you be willing to tell me the story about the day you tried to kill yourself?'" or, for those who have not attempted suicide, "Would you be willing to tell me about the day that you almost killed yourself or you really wanted to kill yourself?"

We invite that patient to share their experience. One of the remarkable things that we're hearing now from patients is they're telling us things like, "No one's ever listened to me like that before. This is the first time I feel like someone's actually cared. I've accomplished more in this 20 minutes talking with you than I have in years of therapy."

More to come on that, but we think that's going to be a really important direction forward.

Flint: Excellent. We definitely look forward to hearing more about that in the future.

Thank you so much for taking the time to sit with us and for presenting here at Psych Congress. I know a lot of clinicians are going to get a lot of great information from your session and really will be able to bring that back to their practice.

Dr Bryan: Thank you.

Flint: Thank you.

Craig Bryan, PsyD, ABPP is a board-certified clinical psychologist with expertise in cognitive-behavioral treatments for individuals experiencing suicidal thoughts and post-traumatic stress disorder (PTSD). Dr Bryan conducts research to help military veterans, first responders and other adults who are dealing with mental health issues. In collaboration with his colleagues, he has developed and demonstrated the effectiveness of brief cognitive-behavioral therapy (BCBT) for suicidal military personnel. Dr Bryan earned both a Master of Science degree in clinical psychology and a Doctor of Psychology in clinical psychology from Baylor University, Waco, Texas, and completed a clinical psychology residency at the Wilford Hall Medical Center, Lackland Air Force Base, Texas. He received a Graduate Certificate in Applied Statistics from Penn State, Centre County, Pennsylvania.