Motivational Intervention for Safety Plan Use in Daily Life: An Interview and Think Aloud Study

Research indicates that a considerable proportion of suicide decisions are made impulsively within minutes. The Safety Plan Intervention (SPI) is a method designed to counteract this impulsivity, encouraging individuals to follow coping strategies instead of acting on suicidal urges. Although SPI is advised for those with suicidal tendencies, about 40% of individuals don’t utilize their safety plans.

This research will inform the development of future interventions for those with substance use and suicidal urges, a group that critically needs innovative suicide prevention strategies.

Suicide is a leading cause of death and a public health crisis, especially among individuals with psychiatric or substance use disorders. Up to 40% of people seeking treatment for substance use disorders have a reported history of one or more suicide attempts. 60% of suicide attempt decisions are made with certainty only within five minutes prior to the act, suggesting the need for timely interventions that can be delivered, when needed, to prevent impulsive decision-making. The Safety Plan Intervention (SPI) is a brief, evidence-based intervention shown to reduce risk for suicide. SPI involves development of a prioritized list of personalized coping strategies and sources of support that the patient can use to respond to suicidal urges, as they arise, rather than impulsively carrying out these urges. SPI is now recommended for routine care of individuals with suicidal urges, however, roughly 40% of patients who have a safety plan report that they never use it.

A key challenge is that people often struggle to apply skills from therapy in real life due to motivational or self-control issues, which are particularly notable in substance use disorders. Motivational Interviewing (MI) has been employed to boost the sustained use of SPI but traditionally requires face-to-face sessions. Some evidence suggests that sending supportive text messages can enhance the use of safety plans. While MI interventions can be technology-driven, combining them with SPI without in-person sessions remains unexplored.

This study will conduct preliminary work to support a future just-in-time adaptive intervention (JITAI) to address this gap, aiming to provide timely support. Using a human-centered design, this study is split into two phases:

Phase 1 evaluates barriers and facilitators for using safety plans in real-time. It involves interviews with patients and providers, discussing the use of mobile safety plans and potential JITAIs. Feedback on motivational and self-control challenges will be a primary focus.
Using Phase 1 feedback, researchers will design prototypes of real-time motivational interventions to boost safety planning engagement. Another round of interviews will collect feedback on these prototypes, using a “think aloud” approach to understand user interaction.

The project aligns with d3center priorities, emphasizing adaptive mobile interventions that offer personalized real-time support. This research will inform the development of future interventions for those with substance use and suicidal urges, a group that critically needs innovative suicide prevention strategies. The study will engage two participant groups: those with prior engagement in a longitudinal study on suicidal thoughts and behaviors, and psychiatric providers. The goal is to improve the real-world application of safety plans, making them more effective and relevant to those at risk.

Principal Investigator

Rebecca Fortgang, PhD
Clinical Psychologist
Instructor, Harvard Medical School
Research Scientist, Center for Precision Psychiatry, Mass. Gen.
Research Associate, Department of Psychology, Harvard University

Key Collaborators

Ewa Czyz, University of Michigan
Walter Dempsey, University of Michigan

Funding Source

d3center Pilot Grant Program

Focus Area

Advancing mobile health interventions