Enhancing motivation and self-efficacy for safety plan use: incorporating motivational interviewing strategies in a brief safety planning intervention for adolescents at risk for suicide

Abstract

Death by suicide is one of the leading causes of death among adolescents in the United States, and risk for recurring suicidal thoughts and behavior remains high after discharge from psychiatric hospitalization. Safety planning, a brief intervention wherein the main focus is on identifying personal coping strategies and resources to mitigate suicidal crises, is a recommended best practice approach for intervening with individuals at risk for suicide. However, anecdotal as well as emerging empirical evidence indicate that adolescents at risk for suicide often do not use their safety plan during the high-risk post-discharge period. Thus, to be maximally effective, we argue that safety planning should be augmented with additional strategies to increase safety plan use to prevent recurrent crises during high-risk transitions. The current paper describes an adjunctive intervention for adolescents at elevated suicide risk that enhances safety planning with motivational interviewing (MI) strategies, with the goal of increasing adolescents’ motivation and strengthening self-efficacy for safety plan use after discharge. We provide an overview of the intervention and its components, focusing the discussion on the in-person individual and family sessions delivered during hospitalization, and describe the theoretical basis for the MI-enhanced intervention. We then provide examples of applying MI during the process of safety planning, including example strategies that aim to elicit motivation and strengthen self-efficacy for safety plan use. We conclude with clinical case material to highlight how these strategies may be incorporated into the safety planning session.

Death by suicide is the second leading cause of death among adolescents in the United States (Centers for Disease Control and Prevention, 2018). In addition, non-lethal suicide attempts and suicidal ideation constitute a major public health concern impacting, respectively, 9% and 19% of high school-aged adolescents each year (Ivey-Stephenson et al., 2020). Paralleling the growing impact of youth suicidal behavior, emergency department (ED) visits and psychiatric hospitalizations for suicide-related reasons have also been on the rise (Mercado, Holland, Leemis, Stone, & Wang, 2017; Plemmons et al., 2018; Zima et al., 2016). Of particular concern, psychiatrically hospitalized adolescents remain at high risk for repeated suicidal behavior and persistent suicidal crises following discharge (Chung et al., 2017; Czyz & King, 2015; Goldston et al., 1999; Yen et al., 2013), suggesting a need for brief interventions targeting the high-risk period after hospitalization that can also be feasibly implemented (Brent et al., 2013; Glenn, Esposito, Porter, & Robinson, 2019).

Our objective is to describe a brief adjunctive intervention, called MI-SafeCope, developed to target reduction in post-discharge suicidal behavior among psychiatrically hospitalized youth. Comprised of three components, MI-SafeCope incorporates a Motivational Interview (MI)-enhanced safety plan (MI-SP) provided to adolescents and parents at the time of psychiatric hospitalization, post-discharge booster calls delivered to adolescents and parents, and daily supportive text messages provided to adolescents. A pilot randomized controlled trial focused on the feasibility and acceptability of MI-SP and booster calls is described elsewhere (Czyz, King, & Biermann, 2019), as is the iterative development of the supportive text messages (Czyz, Arango, Healy, King, & Walton, 2020). Here, our primary focus is on describing the in-person MI-SP component. We begin by describing MI-SP and its guiding theory, which is followed by highlighting its elements and example strategies. We end with case material to illustrate example concepts and strategies. The core elements of MI-informed safety planning as described in this paper were specifically applied in an acute inpatient psychiatric setting, however they could be used in a variety of treatment settings as their central elements will remain largely the same.

I. Overview of MI-SP

Enhancing Best Practice of Safety Planning with Motivational Interviewing

A safety plan is a brief best-practice intervention (Suicide Prevention Resource Center, 2008) designed to mitigate suicide risk by encouraging adaptive coping. Commonly included as an element of treatment protocols for individuals at risk for suicide (Asarnow, Hughes, Babeva, & Sugar, 2017; Brent, Poling, & Goldstein, 2011; Jobes, 2009; Miller, Rathus, & Linehan, 2006; Wenzel, Brown, & Beck, 2009), safety plans have also been used as stand-alone interventions (Stanley & Brown, 2012). Modeled after the Safety Plan Intervention (SPI) developed by Stanley and Brown (2012) and the safety plan protocol for adolescents described by King and colleagues (King, Foster, & Rogalski, 2013), the MI-SP similarly emphasizes identifying personal coping strategies (healthy distraction and relaxation activities, reasons for living, coping statements), personal and professional sources of support (including crisis and emergency services), personal suicide warning signs (when the safety plan should be used), and steps for ensuring a safe environment. MI-SP is used with the goal of developing a personalized safety plan while simultaneously incorporating principles and strategies of MI (Miller & Rollnick, 2013) to address potential challenges to its use. Specifically, previous work has shown that approximately 60% of discharged adolescents do not look at their safety plans following hospitalization and more than half do not try to use coping strategies when experiencing thoughts of suicide (Klaus, 2011). Moreover, safety plan use among suicidal adolescents has a notable decline in the days after discharge, even in the presence of suicidal thoughts (Czyz et al., 2019). As such, MI is used as an explicit strategy to enhance adolescents’ motivation and self-efficacy to sustain safety plan and coping use. The MI-SP includes a 60-minute individual session with the adolescent, during which the safety plan is developed, and a 30-minute family session to share the safety plan and related safety recommendations with the parent.

Individual session

The primary purpose of the individual session is for the clinician and adolescent to collaboratively create a personalized safety plan while the clinician incorporates MI strategies to elicit the adolescent’s motivation and commitment to using the safety plan and healthy coping after discharge. After developing the safety plan, a portion of the session is spent discussing the “how” and “when” related to its use, including how the safety plan will be stored and retrieved, whose support will be enlisted in using the plan, as well as ideas for addressing barriers to its use. Finally, the clinician and the adolescent identify a plan for how the adolescent will share the safety plan during the family session as well as ideas for how the parent might support the adolescent in using the safety plan.

Family session

The purpose of the family session is to share the safety plan with the parent and, with input from the adolescent, discuss how the parent can best support their adolescent in using the plan. In the event that the adolescent expresses a high level of reluctance to share the entire copy of their safety plan (e.g., due to strained relationship or high conflict), the clinician may take on a more active role in assisting the adolescent in sharing its key components. Moreover, any safety-related concerns are discussed with the parent, with the adolescent providing input about how this information is shared. All parents are provided with a crisis support card, which is completed during the family session with input from both the parent and adolescent, that summarizes information about the adolescent’s individual warning signs, lists steps for ensuring a safe environment (lethal means restriction), includes a reminder about risk monitoring and inquiring about thoughts of suicide, provides crisis contact numbers, and lists specific and individualized ideas for how the parent will support their adolescent in a crisis. The clinician uses MI strategies to deliver the content of the session while attending to parental motivation and self-efficacy to support their adolescent after discharge and to encourage their adolescent’s safety plan use.

II. Guiding Framework and Relevant Strategies

Originally developed by Miller and Rollnick in the context of substance use treatment, MI is a collaborative and person-centered, yet directive, communication style aimed at enhancing intrinsic motivation and self-efficacy to achieve behavior change (Miller & Rollnick, 2013). In the individual session, where the focus is on creating a personalized safety plan, the clinician relies on an MI-consistent guiding style. As described by Miller and Rollnick (2013), guiding is the middle ground between following and directing, thus allowing the clinician to both listen in tandem with providing direction and expertise when needed and with client permission. The application of MI during the process of safety planning is consistent with Self-Efficacy Theory and Self-Determination Theory. In brief, Self-Efficacy Theory posits that a person approaches challenges based on their feelings of capability to address those challenges that ultimately lead to behavior (Bandura, 1977; Bandura, 1982), whereas Self-Determination Theory posits that intrinsic motivation is more powerful for lasting behavior change than extrinsic motivation (Deci & Ryan, 2004, 2012). In line with these theoretical frameworks, MI-SP relies on an MI-consistent communication style that aims to increase the suicidal adolescent’s intrinsic motivation for change (safety plan use) and enhance their sense of self-efficacy to achieve this change, particularly in times of crisis when adaptive coping may be more challenging. More broadly, MI is also used to facilitate engagement when adolescents may be ambivalent or reluctant to take part in the discussion about safety planning. MI strategies are used to help the adolescent feel heard and to give them an active voice in their care while respecting their autonomy to choose what is included on their safety plan.

Four Phases of MI

Miller and Rollnick (2013) describe the process of MI being comprised of four recursive stages: engaging, focusing, evoking, and planning. Similarly, these phases guide the process of delivering MI-SP. Engaging, or the first phase, focuses on building a trusting and collaborative relationship with the client. Applied to MI-SP, the clinician communicates acceptance and understanding of the adolescent’s perspective as they are sharing information about the recent suicidal crisis that brought them to the hospital. Importantly, some details about the adolescent’s story—including specific risk that contributed to the crisis and protective factors that prevented its exacerbation—may be used later in the session to assist the adolescent in identifying specific warning signs and coping (e.g., reasons for living). The second phase, i.e. focusing, involves developing a clear target or focus of intervention. In the case of MI-SP, the clinician specifies the purpose of the session and establishes the focus as collaboratively developing the safety plan. The third phase of evoking places emphasis on eliciting motivation for change (the “why” of change) and self-efficacy or confidence to change (the “how” of change). Applied to MI-SP, this involves targeted steps of collaboratively developing an individualized safety plan while explicitly using a series of MI-consistent strategies to explore and evoke the adolescent’s motivation and self-efficacy to use the identified strategies. Planning, the fourth phase, involves the clinician helping the individual make their own plan for how they will implement the behavioral change. Applied to MI-SP, this involves eliciting practical plans and steps for implementing the safety plan (e.g., where and how it will be stored; steps for increasing the likelihood of safety plan use; whose support will be enlisted, etc.) while addressing possible barriers to its use. Through the use of MI-consistent strategies, the clinician also attends to the adolescent’s readiness and self-efficacy to implement these steps after discharge. While these four phases generally build upon each other in a somewhat linear fashion, Miller and Rollnick (2013) stress that the phases can be recursive. For example, engagement is important throughout the entire session, rather than just at the beginning, and focusing may be revisited as needed at many points in the session. Applied to MI-SP, these four phases guide the delivery of both the individual and family sessions and are also used to orient clinicians during follow-up phone calls.

Example Strategies

While describing all MI strategies is beyond the scope of this paper, example strategies used as part of MI-SP are briefly summarized below. The reader is encouraged to review the main source on MI (Miller & Rollnick, 2013) for additional detailed information on MI and its strategies. While some MI strategies may be used more frequently at specific points during the session (e.g. eliciting and enhancing change talk strategies are heavily relied on in the evoking phase), these strategies may be applied throughout the session and irrespective of phase.

OARS

Throughout MI-SP, the clinician relies heavily on a set of foundational MI strategies represented by the acronym OARS: Open-ended questions, Affirmations, Reflective listening, and Summaries (Miller & Rollnick, 2013). Used as the core set of strategies, OARS are thus instrumental in guiding the delivery of MI-SP. For example, in the engagement phase, OARS are used to learn about the suicidal crisis that brough the adolescent to the hospital while establishing a collaborative and accepting tone that is central to MI-SP. For example, the clinician may use Open-ended questions and complex Reflections to understand and elicit the adolescent’s perspective and experience. OARS are also used in the evoking phase to facilitate the process of eliciting the adolescent’s motivation for change (safety plan use, coping use) and confidence in change. The clinician may use Open-ended questions to ask for elaboration or more details (e.g., “What do you find supportive about this person?’ or “What about this coping strategy relaxes or comforts you?”) to elicit reasons for using a particular coping strategy (i.e. reason for change); Affirmation to comment positively on a client’s strengths, efforts, or abilities that focus on the adolescent (e.g., “You have a good sense of who your ‘go to’ supports are, and are quite determined to use these”); Reflection to deepen understanding of the client’s perspective and strengthen change talk by highlighting the adolescent’s own arguments or ideas for change (e.g., “For you, feeling down is a barrier and yet you have some ideas about how to work around it, like texting your mom”); and Summaries to combine together what the adolescent has said, particularly emphasizing the adolescent’s motivation for change, or to use as a transition before moving to another part of the session.

Providing information with permission

Consistent with the guiding style of MI, and in order to facilitate collaboration and client autonomy, the clinician strives to provide information to the adolescent after gaining permission or at client request. One of the approaches for providing information is the MI strategy of Elicit-Provide-Elicit (Miller & Rollnick, 2013). Before providing information, the clinician elicits permission (e.g. “Would it be alright if I told you a little bit about…?”) or tries to first learn about the client’s knowledge or experience (“What, if anything, have you heard about safety plans?”). The clinician then provides the information while acknowledging the client’s freedom to disagree. Finally, the clinician uses open-ended questions to elicit the client’s understanding or response to the information (e.g. “What do you make of that?” or “How might that apply to you?”). For example, instead of saying, “Here is the crisis line number,” the clinician might ask, “What, if anything, do you already know about contacting a crisis line?” Often the adolescent has heard of, or has personally used, a crisis line. This opens up a conversation for the adolescent to share what they already know as well as to further explore the benefits of, or the barriers to, using a crisis line from their own perspective. The clinician could then provide additional details or correct any misunderstanding before eliciting from the adolescent how that may or may not fit with their prior understanding.

It is important to note that the clinicians may also employ more nuanced MI-consistent approaches for sharing information that are not direct queries for permission but rely on language that emphasizes client choice and autonomy (Miller & Rollnick, 2013). For example, if the adolescent struggles with generating coping strategies, the clinician may say: “It’s really up to you, but I can share some ideas that have worked for others.” In another example, the clinician may offer to share resources (e.g., list of coping strategies) while acknowledging choice and freedom to disagree: “I wonder if there is anything on this list here that might appeal to you?”. In some circumstances, such as when discussing critical information that the clinician is obligated to share (e.g., lethal means restriction), the clinician may intentionally decide to not explicitly ask for permission and instead rely on autonomy-supportive language before providing such information (e.g., “I wonder what you’ll think about this…”). Even with the more subtle strategies for obtaining permission, the clinician still strives to elicit the adolescent’s or parent’s understanding or response to what the clinician has shared.

Eliciting and Enhancing Change Talk

In order to strengthen motivation for behavior change throughout the MI-SP session, the clinician uses MI-congruent strategies to respond to “sustain talk” as well as enhance and affirm “change talk.” Sustain talk refers to statements that reflect the side of ambivalence indicating reluctance to change (e.g. not using the safety plan or coping strategies). For example, “When I’m down, I’m so upset I don’t think I will look at my safety plan.” On the other hand, change talk reflects the part of ambivalence that favors change, such as desire, ability, or reasons for change. It may sound like, “I want to use my safety plan because I want to keep myself safe. I don’t want to hurt myself or my family.” Clinicians may use a number of strategies to validate and respond to sustain talk while also attending to and eliciting change talk. For example, a clinician might use a double-sided reflection being careful to end the reflection with change talk and connecting with “and” instead of “but”: “You’re anticipating that it might be more difficult to use your safety plan when you’re upset [sustain talk] and you shared just how important it is for you to keep yourself safe, especially as you think about your family [change talk].” Another example might occur when the adolescent may be reluctant to contact a crisis line: “You mentioned it’s hard to reach out to people when you are struggling and it might be kind of scary to call the crisis line [sustain talk]. At the same time, you also wish you weren’t alone during those times [change talk]. What are some situations when you would consider calling the crisis line, if you decided to?” Such reflective statements, along with open-ended questions, do not overlook the client’s expressed ambivalence or barriers; instead, they strategically invite the client to elaborate, in their own words, on the importance, advantages, or reasons for change.

Strengthening self-efficacy

The clinician might also use a series of strategies to enhance self-efficacy to use the safety plan and coping more broadly. Some examples include: using a confidence ruler (e.g. “On a scale of 0 to 10, with 0 being not at all confident, and 10 being most confident, how confident are you that you could use your safety plan at a time of crisis?”, which is followed by a question of “Why did you choose a 5 and not a 2?” [a lower number to elicit more confidence]; another follow-up question might ask “What steps would you need to take to go from a 5 to an 8?”[a higher number to elicit confidence]); troubleshooting response to barriers in using the safety plan (“What might be some ways of dealing with this?”); eliciting personal strengths and applying them to the safety plan (“How will these strengths help you succeed in sticking to the safety plan?”); and asking questions meant to elicit support (“Who could help you with sticking to the safety plan?” or “In what ways can your mom help you stick to using the safety plan?”).

III. Example Applications to Safety Planning Process

Introduction of the Safety Plan

After the clinician is familiar with the events leading up to the recent crisis and hospitalization, they shift to introducing the safety plan while maintaining a collaborative stance, communicating acceptance, and emphasizing the adolescent’s autonomy. For example, the clinician might say: “Given what you shared, I can understand how you or someone in your situation might have felt a strong urge to end their life. If it’s okay with you, I’m hoping that we can work together to explore some ideas for dealing with future thoughts of suicide. But it’ll be up to you to decide what those things might be.” Using the strategy of Elicit-Provide-Elicit, the clinician asks about the adolescent’s knowledge of, and any experiences with, safety planning that might also provide information about the adolescent’s ambivalence or barriers. For example, the clinician might ask: “What, if anything, have your heard about safety plans?”. Depending on the adolescent’s response, the clinician might affirm any knowledge or experience with safety plans before providing additional information about safety plans using the MI-consistent approach of information sharing with permission (e.g., “Would it be alright if I told you a bit more about it?”). The information provided by the clinician intentionally affirms the adolescent’s choice and autonomy; for example: “A safety plan is a personal plan for coping with thoughts of suicide or urges to end your life. It is your own individualized plan, not something I or anyone else can tell you to do. It usually has personal strategies for coping with thoughts of suicide so that they don’t have to progress to action.” Next, consistent with the Elicit-Provide-Elicit strategy, the clinician will inquire about the adolescent’s reaction and understanding (e.g., “What do you think about that?” or “How does that sound to you?”). Finally, in the process of sharing the safety plan template that includes the common safety plan elements, the clinician will continue to use collaborative and autonomy-supportive language, for example: “Here’s something for us to use as we keep talking together. You will see here a place to include different strategies that can be useful at a time of crisis. Some of these may appeal better or not as much to you. It’s really up to you what will be included here.” This MI-consistent language allows the adolescent to move into the safety planning portion of the session feeling that they are autonomous in creating the safety plan that is best for them.

Evaluating and Modifying the Effectiveness of the Safety Plan

Once the clinician has collaboratively guided the adolescent through the process of developing their personal safety plan, the next part of the session is devoted to further assessing and strengthening the client’s motivation, self-efficacy, and commitment to follow through with using their safety plan. The clinician relies on some of the strategies discussed in the above sections. For example, to strengthen motivation, the clinician might use OARS to elicit the advantages of and reasons for safety plan use as well as draw on the importance rulers, as described above. Thus, the clinician elicits from the adolescent what specific benefits they may see in using the safety plan (the “why”) to increase the adolescent’s motivation and commitment to its use. This portion of the session includes discussion of where the adolescent might want to keep the plan and what specific actions will make it more likely they will use the plan, including what kind of support (and from whom) the adolescent may need to implement the plan. In this portion of the session, the clinician will also assess and strengthen the adolescent’s self-efficacy to use the safety plan (i.e. the “how”). The clinician draws on a number of tools, described above, such as applying the confidence ruler, eliciting qualities and strengths, using queries meant to elicit other’s support that could increase sense of self-efficacy, and brainstorming anticipated barriers and possible solutions (“Knowing yourself as well as you do, how could you handle [the barrier]?”). This portion of the session allows the clinician to gauge the level of motivation and self-efficacy to use the safety plan, which may result in making adjustments to coping strategies or how the plan will be used, as well as discussion of “next steps” intended to increase the likelihood of safety plan use. Critically, this portion of the session is also used to discuss specific ideas for enlisting the parent’s support, from the adolescent’s perspective, to help sustain safety plan and coping use post-discharge.

Importantly, while care is taken to develop a personally relevant safety plan with the adolescent, barriers and challenges to using the safety plan may arise post discharge. To address this, MI-SafeCope includes post-discharge contacts through daily supportive text messages, which are delivered in an automated form, and booster phone calls that are carried out separately with the adolescent and parent. Similarly adhering to MI strategies, the booster calls are intended to further enhance self-efficacy and motivation for safety plan use, address barriers that interfered with using the safety plan, and discuss needed modifications. Although beyond the scope of this paper, preliminary results indicate that these follow-up strategies may beneficially augment MI-SP in terms of increasing post-discharge safety plan use, coping by support seeking, and self-efficacy (Czyz et al., 2020).

IV. Clinical Exchange Examples

We provide example clinical exchanges to illustrate the portion of the session that follows safety plan development described in the section above. In order to protect client confidentiality, this material is based on an amalgam of cases. The adolescent depicted in these exchanges had a long history of mental health service use and was able to easily identify strategies to include on their safety plan. However, due to a recent interpersonal crisis and a suicide attempt, they were less confident in their ability to use these strategies and exhibited some ambivalence around using the plan.

Clinician: Thank you for all you’ve shared today. I appreciate how open you’ve been about what the last few days have been like for you. You also have some really great ideas for what you can do to keep yourself safe during a crisis. The clinician summarizes specific coping ideas and strategies. You feel especially confident about using relaxation and distraction, and also reaching out to your mom. What do you think about the plan you came up with?

Client: I like how it has all of these different sections where I can, you know, like remember all of my warning signs and coping skills. They’re organized how I like it, you know, and I never really wrote them all down before. But I’m just not sure if I will use it.

Clinician: I know you told me you’ve done this before and so it makes sense you’re feeling a bit skeptical. It also sounds like there are some things about it that you like – it’s organized in a way that makes sense to you. Let’s say you did decide to use it in the future - what would be some advantages of using your safety plan, if you decided to?

Client: Um, I guess it probably would make my mom happy a little bit that I’m trying. And um, it would keep me out of the hospital, because I really want to get better this time and it’s important that I do that because, like I told you, I want to apply to college this year.

Clinician: From your perspective, using the plan might reassure your mom that you’re trying to keep yourself safe and it’s important to you that she sees you trying. You also see the connection between practicing your coping strategies and getting better so that you can accomplish your goals.

Client: Yeah, I can’t go to college if I’m feeling this way. I really need to get better this time.

Clinician: It’s important to you that you stay out of the hospital and get healthier to help you accomplish your goals. You also really value doing well in school and are very committed to catching up.

Client: Yeah, being in this hospital has really set me back with school work and when I go back I’m worried it might be even more stressful.

Clinician: That makes sense. I know you noted that pressure from school work, and sometimes even being at school, can feel like a trigger for you. What might be some benefits of using the safety plan at school, if you decided to?

Client: Well, school is stressful and there are lots of times when I’m like, pretty upset there. But the plan might not work there because I can’t do these strategies at school. I can’t walk my dog, I can’t, you know, take a bath at school if I’m upset.

Clinician: That’s true, you definitely can’t take a bath at school. It’s great that you know that about yourself - that certain strategies work better in different environments. Clinician and client discuss which strategies would be most useful at school before the clinician returns to eliciting how the plan will be used in that context. I’m wondering if it would make sense for us to consider how you might go about using the safety plan at school and what would make it more likely? Where might you keep it? After discussing where the client will store the safety plan - both at home and school - and who should have a copy, the client decides to keep the safety plan on her cellphone, behind her closet door, and to give a copy to her mother and school counselor. The clinician then elicits additional ideas for making it more likely the safety plan will be used, focusing on specific steps after discharge. The clinician subsequently focuses the session on strengthening confidence in using the safety plan. For example:

Clinician: How confident are you that, if you were in a crisis, you could use your safety plan? With 0 being not at all confident, and 10 being very confident?

Client: Um… Probably a 6.

Clinician: Seems like you are feeling pretty confident! Why didn’t you choose a lower number, like a 2?

Client: Well, you know, we spent like a whole hour creating it and it’s really detailed. It’s actually something I came up with, not like just a bunch of coping skills someone just handed to me. And I’ll be able to see it on my phone if I need it. I guess also sharing it with my mom and counselor make me feel more confident that I’m not alone.

Clinician: Right, you put so much effort and thought into this plan and you came up with the strategies that you are willing to try. And it’s such a strength that you are able to reach out to your support systems to help, both at school and at home. What do you think it would take for you to go from a 6 to a higher number, like an 8? The clinician continues eliciting self-efficacy, focusing on discussing the client’s qualities and strengths that may help the adolescent use their safety plan. A discussion of how the adolescent will address possible barriers to safety plan use is used as an additional strategy for increasing sense of self-efficacy. The clinician ends this portion of the session by providing a summary that highlights and affirms the adolescent’s commitment and self-efficacy to use the safety plan.

V. Conclusion

We described the three-component MI-SafeCope intervention for adolescents at elevated suicide risk, emphasizing its central MI-SP component—an approach to safety planning that is enhanced with MI. Although skilled clinicians may be intuitively using MI-consistent skills (e.g. abundant use of open-ended questions, reflective statements, affirmations), MI-SP was designed to explicitly draw on MI strategies during the process of safety planning and intentionally attend to issues of self-efficacy and motivation that may interfere with safety plan use. Although not the focus of the current paper, MI-SafeCope also incorporates post-discharge contacts that place further emphasis on strengthening self-efficacy and motivation to sustain safety plan and coping use, which may be especially salient following acute psychiatric care. While there is initial evidence showing that MI-SP is acceptable to youth and parents, large-scale studies are needed before the efficacy of this approach can be demonstrated.

Clinical Impact Statement.

Question:

This article documents how motivational interviewing strategies can be applied in a safety planning session.

Findings:

This article provides example strategies illustrating how MI might be applied to guide the process of developing a safety plan.

Meaning:

Motivational interview strategies may offer a useful approach for facilitating client engagement during the process of safety planning.

Next Steps:

Large trials are needed to demonstrate efficacy of the intervention in adolescent populations and should be explored for additional populations as well.