Safety Planning for Suicidal Ideation as a Form of Nervous System Regulation

When I was in my early 20s, I spent three years volunteering on Canada’s National Suicide Prevention Hotline, now called Talk Suicide (1.833.456.4566). As part of the on-boarding process we were required to complete 40-hours of classroom training, pass a role play examination, sit in on experienced volunteer’s calls and complete calls under supervision all before becoming independent on the phone lines.

The foundation of our training was to teach us how to actively listen and safety plan with callers. Listen first. Reveal little. Centre the client, they are the expert on their lives. And always, always, always assess for risk. How often have you had these thoughts? How long do they last? Have you made any arrangements? Have you been drinking or using drugs? I had my questions memorized and was given an outline for how to respond at each level of risk (low, medium, high, and active). And yet despite all this hands-on training, I still felt woefully unprepared when faced with an actual caller begging for respite.

Indeed, many callers become more familiar with our training than even the most experienced volunteers. They have spoken to us many times before and therefore they can hear the echoes of our training scratch away at our humanity. When the questionnaire creates a shield between themselves and the responder they are trying so desperately to connect with, they speak louder to be heard, often literally crying out for help.

I like to think I found ways to circumvent this phenomenon by centring the person in front of me. Ask the questions, without asking. Listen for hope and hold onto it. See glimmers of the ways that they look to the future without blatantly asking them to list their reasons for living. Have a human conversation even if it means you don’t check every box. In many ways, these skills have stayed with me, even now as a psychotherapist.

However, my system was not perfect. I would often hear the echo “distraction, distraction, distraction. Everyone is always just asking me to distract myself from these thoughts and I’m tired of it.” I had no rationale to justify why journalling may keep these thoughts at bay, why watching a re-run of The Office may help you hold on for one more night, why a cold shower may be the only way to wash away the hours of pain that lay ahead. I empathized with their frustration, but what more could I do?

Since then, I have often reflected on how those with the least experience, often occupy the frontlines of our mental health crisis. It is an unfair irony. Research says that an experienced volunteer may be just as effective as a trained professional, but I knew I was lacking justification for my actions and in that sense, I felt like an empty actor. I wished I could do more.

Now as a trained somatic therapist, I understand from a different perspective what I was trying to accomplish on all those long, sleepless nights (a perspective I needed at the time): I was regulating nervous systems. A robust body of research has confirmed that emotional dysregulation predicts suicidal ideation (especially in teens). But what is actually happening to our body during self-reported emotional dysregulation? This is where Polyvagal Theory comes in.

Polyvagal Theory (developed by Stephen Porges) explains the physiology of emotion regulation. In the parasympathetic nervous system, the vagus nerve connects the heart to brain. In safe environments, the vagus nerve acts as a “brake” on the sympathetic nervous system (fight-flight). When the brake is engaged, we feel safe, our heart rate decreases, we relax. When the brake is released, we become aroused. Our “neuroception” of an environment (how we perceive safety or social connection), determines whether or not the brake is engaged. In this way cardiac vagal tone (or the health of our vagus nerve as measured by a respiratory sinus arrhythmia (RSA) test) can be used as a physiological marker of self-regulation. New research has shown that women with a greater relative RSA decrease to a laboratory stressor experienced greater suicidal ideation 3- 6- and 9-months after the test was performed.

Furthermore, while our nervous systems change when in contact with another person, the health of our nervous system also determines the impact of social support. We call this co-regulation. Connection activates the vagus nerve, which helps people apply the “brake” on sympathetic activation (fight-flight). People should soften in the presence of safety. However, if our ability to regulate is impacted on a physiological level, social support becomes less impactful. In the same study mentioned above, the researchers found that physiology moderated the effects of social support. In other words, the women who experienced greater relative RSA decreases, also showed a lesser ideation in relation to friendship support.

So, when I asked a client what they could do to make it through the night, what I was truly asking is how can they shift their nervous system state to feel safe? How can I help make their body a more bearable place to occupy? Together, how can we create space for them to survive? Having this perspective today, helps me feel more confident when approaching suicidal ideation. I know that it is a slow process that starts with healing the nervous system by finding ways to apply the vagal brake. In this way, I hope that Polyvagal theory may become another tool in our toolkits for both managing suicidal ideation and healing from it.

References

Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124, 111–126.

Giletta, M., Hastings, P., Rudolph, K., Bauer, D., Nock, M., & Prinstein, M. (2017). Suicide ideation among high-risk adolescent females: Examining the interplay between parasympathetic regulation and friendship support. Development and Psychopathology, 29(4), 1161-1175. doi:10.1017/S0954579416001218

Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74, 116–143.