In working with the Collaborative Assessment and Management of Suicidality (CAMS), I concentrate on what I call "Drivers," which are the specific areas or life circumstances that cause an individual to want to die (e.g., loss of a job, loss of family, etc.). To empower the Stabilization Plan from session to session, I have created a "Living Document" based on "near misses" that we update each week. This process is similar to a post-game analysis in sports. We also take a specialized approach to the Stabilization Plan: instead of identifying general coping skills, we use Implementation Intentions based on the "If-Then" model. For example, if someone is staring at the medicine cabinet (the trigger), then the Implementation Intention would be that they immediately go to the kitchen and drink a glass of ice water. One of my most successful additions to the Stabilization Plan is a "Red Flag Communication Protocol." We include a line stating that when a person feels their "Internal Agitation" has reached a Level 7, they will text a designated person the code word "ORANGE." This informs their support system that they are struggling without requiring a full explanation. This approach significantly reduces barriers to seeking help. Many chronically suicidal individuals feel like they would be a burden to those they reach out to and do not wish to initiate a "heavy-duty" conversation about their ideation. By utilizing an agreed-upon code word, the individual can reach their supportive people without the additional stress of explaining their situation.
In modifying the Stanley-Brown Safety Plan to accommodate chronic ideation, I focus on shifting from "Abstract Safety" to "Micro-Interventions" that target the particular levels of cognitive dissonance experienced by the client between appointments. Because clients struggling with chronic issues often begin to view the standard safety plan as "wallpaper"—something they see but no longer process—I incorporate the "Lethality Leveling" concept into Steps 3 and 4 (Social Situations and Social Support). This allows clients to distinguish between individuals with whom they can simply be present in silence and those with whom they can actually speak about their pain. By making this distinction, we limit the social fatigue that typically increases risk levels in social situations. The specific statement I have added that has caused the most significant change in clients is: "If I feel my Reasons for Living today are lies, I will complete one 'Neutral Maintenance' task." I include this on the front of the plan because chronic clients may regularly experience "hope fatigue," where viewing pictures of family or envisioning a positive future causes more pain than comfort. By giving them permission to pivot to a neutral task (e.g., washing a single dish, bathing, etc.), the bar for success is lowered. This allows them to maintain a sense of agency without having to force an emotional state that is currently inaccessible to them.
Actionability can be enhanced when the plan is changed to containment that is not crisis but rather day to day. One particular addition which alters the subsequent steps to be followed is a written line which creates the firstest internal indication which will be taken to mean that the plan ought to be opened. Instead of waiting until one thinks about self harm the plan identifies a specific state, like two nights of poor sleep, skipping meals, or reenacting a particular story. This cue is self-identified by the clients. That timing matters. After the trigger being named, the second step is that of compressed. One of the actions identified in the plan can be accomplished in less than five minutes and is not dependent on motivation. As a sample, it may be sitting in a particular chair, texting one word to a respective contact, or opening a note with a grounding language that is written in a stable session. It focuses on initiation rather than relief. This change helps to cut the ambiguity between sessions. There is no longer a debate among clients on whether things are bad enough. The cue provides the response to that. Subsequently, follow-up sessions are followed by a review on whether the cue came and whether the first action was taken and not whether the client felt better. This adaptation helps in chronic ideation as it respects its permanency. The plan is turned into a day-to-day containment instrument instead of an emergency document. Coherence is enhanced as the initial step is concise and definite and it is pegged on observable experience.