Use of Safety Planning Among 9-8-8-Network Crisis Centers in Missouri: A Mixed Methods Study

Background and Purpose: Suicide rates have been steadily increasing in the US over several decades. To reduce suicidality, the federal government aimed to improve access to crisis lines by replacing the 10-digit National Suicide Prevention Lifeline with the easy-to-remember number, 9-8-8. This initiative resulted in an influx of federal, state, and local funding for contracted nonprofit crisis centers in charge of implementing the crisis lines and corresponding increased requirements related to quality standards. Some of these standards include the use of Safety Planning, an evidence-based intervention for suicide prevention. As such, the national 988 policy change is an intervention that can affect both access and quality of care provided to callers. The aim of the current study was to understand organizational challenges and facilitators associated with using Safety Planning from the perspective of frontline crisis-line counselors and crisis-center management in the state of Missouri – a state recently ranked as a national leader on metrics of 988 access (e.g. answer rate, response time).

Methods: Using a convergent triangulation mixed methods design, data were collected from July-November 2023. Crisis-line counselors and management from all six 988-participating crisis-centers in Missouri were invited to participate in an online survey, where workers responded to validated measures of appropriateness (IAM), feasibility (FIM), and acceptability (AIM) of Safety Planning. Qualitative semi-structured interviews were conducted with survey participants indicating interest. Interview questions were informed by the Consolidated Framework for Implementation Research (CFIR; e.g. outer- and inner-setting factors).

For quantitative analyses, the authors fit three multiple regression models predicting IAM, FIM, and AIM scores with staff characteristics as predictors, including clustered errors and a random intercept for the organization.

Qualitative coding followed the Twenty-First-Century flexible coding approach, combining deductive (codes derived from CFIR) and inductive methods. Six researchers independently coded interviews and met weekly to continuously compare themes, patterns, and concepts found in the data.

Results: 77 crisis-line counselors and 20 managers completed the survey. Average scores on the IAM, FIM, and AIM were high (mean ≥ 4.3 on a 5-point scale), indicating the ease of using Safety Planning, although having graduate-level education was negatively associated with all measures.

Twenty-eight interviews were conducted with crisis-center workers and management. Factors related to caller characteristics and their context (e.g., youth callers, callers not having insight into triggers, substance use, prior negative experience with crisis services) and the lack of capacity of social service systems emerged as challenges to implementing Safety Planning effectively. The adaptability of Safety Planning, strong leadership support, quality assurance systems, and informal support from co-workers emerged as facilitators. Participants emphasized the importance of positive reinforcement from management and being caller-centered.

Conclusions and Implications: Among nonprofit crisis centers in Missouri, Safety Planning has been established as a core component of care provided to 988 callers, with strong organizational and leadership support. More work needs to be done to strengthen the capacity of social service systems and the continuum of care, as even ideal implementation of evidence-based practices among 988 crisis-line centers is insufficient to meet many callers’ needs.