Does one size fit all? Adapting Safety Planning Intervention with and for autistic adults

By Emma Nielsen.

There is always a to-do list on my desk. It is usually scrawled across a scrap piece of paper, often elaborately highlighted and probably makes little sense to anyone else. But it is always there and it makes sense to me. It means that in times when I am overwhelmed or bouncing between meetings and projects I can take a moment to ground myself, find some structure and remember what my next steps and priorities are. And the planning doesn’t stop there; I have a phone, kitchen pinboard and diary full of paper-based and electronic reminders and I know that I am not the only one. All these things help our lives to run more smoothly and help to make us feel more prepared. But are we planning for the really important stuff? Would we know what to do if we started to experience a suicidal crisis?

Safety Planning Intervention [1] is a brief – and arguable simple – intervention to help prevent suicide. The tool helps people to plan, thinking ahead of time about what might help them to safely navigate a future crisis. There is space to think about warning signs that might appear before a crisis, internal coping strategies that might help in the face of a crisis, people and professionals that are known to the individual and who might be contactable for distraction or support, and ways to make the environment safer. It is like a to-do list for when things get tough.

A recent meta-analysis indicated that safety planning-type interventions are effective in reducing the risk of suicidal behaviour in adults. However, there does not seem to be any impact on reported suicidal ideation [2]. Of the six studies included in the meta-analysis, participants were recruited from Emergency Departments, Veterans Health Administration Emergency Departments and case management services. But does safety planning work for all at-risk groups? The simple answer is that we don’t really know. What we do know from other areas of research is that interventions sometimes need adapting to meet the specific needs of particular groups, in order to be accessible, meaningful and effective [e.g., 3].

Autistic adults are one group that we should consider here [3]. We know that autistic adults are at a greatly increased risk of experiencing suicidal thoughts, of attempting suicide and of dying by suicide compared to the general population [4, 5]. We also know that autistic people have differences in social communication and often have restricted, repetitive patterns of behaviours compared to non-autistic people. These differences could impact upon interventions, such as safety planning. For example, these differences might mean that imprecise language and broad questions are difficult for an autistic adult to respond to and it might be a challenge for someone to generate alternative solutions. For some, these differences could also be potentially helpful in developing a safety plan, particularly in thinking about internal coping strategies (where an autistic individual might have particularly strong passions and interests).

Despite evidence of need, there are currently no suicide interventions developed specifically for autistic adults. In our current project we are working with autistic adults and those who support them (i.e., family, friends, professionals) to develop an Autism Adapted Safety Plan and to test how useful and usable adapted safety plans are with this population. To do this, we are currently recruiting UK-based autistic adults with a recent (past 6-month) history of self-harm and/or suicidal thoughts and/or behaviours. After completing some measures about health, mental health, life experiences and their current circumstances, half of these adults will be randomised to develop an Autism Adapted Safety Plan, with a trained service provider, in addition to their usual care. The other half of the participants will continue with their usual treatment (without completing an Autism Adapted Safety Plan). We will follow up with people over a period of 6 months to see how they are getting on and to gather feedback about experiences of developing and delivering Autism Adapted Safety Plans. It is hoped that we will then be able to use this information to further develop the Autism Adapted Safety Plans and to plan a future, fully powered, randomised control trial.

Does this sound like something that you would be interested to know more about? Do you support autistic adults and would you like to learn more about partnering with the project to receive training around safety plans and to help support someone to develop their own safety plan? We would be keen to hear from you. Further details about the project and our current partners can be found on our website and you can reach us at aasp@newcastle.ac.uk.

I would love to be able to add a scheduled call or an e-mail conversation with you to the to-do list on my desk.

Acknowledgements

The study team wishes to thank the project Advisory Group for sharing their experiences to shape up the project and our study partners, without whom this work would not be possible. This study is funded by the National Institute for Health Research (NIHR) Public Health Research Programme (NIHR129196).

References

1. Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001
2. Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D, Erlangsen, A., Portzky, G. et al (2021). Safety planning-type interventions for suicide prevention: meta-analysis. The British Journal of Psychiatry, 219(2), 419-426. https://doi.org/10.1192/bjp.2021.50
3. NICE (2012). Autism spectrum disorder in adults: Diagnosis and management. Retrieved from https://www.nice.org.uk/guidance/CG142
4. Cassidy, S., & Rodgers, J. (2017). Understanding and prevention of suicide in autism. The Lancet Psychiatry, 4(6), E11. https://doi.org/10.1016/S2215-0366(17)30162-1
5. Kõlves, K., Fitzgerald, C., Nordentoft, M., Wood, S. J., & Erlangsen, A. (2021). Assessment of suicidal behaviors among individuals with autism spectrum disorder in Denmark. JAMA Network Open, 4(1), e2033565. https://doi:10.1001/jamanetworkopen.2020.33565

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*Article featuring photo by Marcos Paulo Prado on Unsplash.