There are opportunities to set up such spaces within aftercare services or GP practices. These spaces can be equipped with sensory tools for emotional regulation, which can assist the person in distress to calm down.29 Sensory tools aim to be relaxing and can focus on sight, smell (aromatherapy), touch (e.g. stress balls, weighted fabrics), taste (e.g. sweet or salty food, tea), hearing (relaxing sounds) or proprioception (rocking chairs).
There is a plethora of community supports for mental health and suicide prevention including online resources and phone numbers through which people can speak to mental health professionals. Some of these are listed in Box 3.
For some patients, their care may include a range of self-direction, personal supports, community supports and professional supports. Professional supports may be health related, financial, social, legal or vocational. These can be located in the community or in hospital as voluntary or involuntary admission. Framing the care as a whole-of-team approach, in which different levels of care may be necessary at different recovery points, can assist the discussion regarding at which point different levels of care may be enacted. This can be part of the safety plan. Having the person be part of the plan can be pivotal to retaining the relationship when involuntary care is required.
Referral of patients at suicide risk to tertiary services is one of the more challenging referrals that GPs undertake. This usually involves a phone conversation with an intake worker who is trying to assess risk and usually balancing highly limited inpatient hospital resources. The GP can assist by having important information at hand, such as previous suicidal behaviours, previous psychiatric history, whether or not the patient has suicidal thoughts, suicidal ideation, intention, a clear method and access to means. Hospital admissions can sometimes be a circuit breaker and a haven of safety during an acute crisis, but the reality is that many of these patients then get discharged back to the GP who is still managing some degree of suicidal risk. Working with a team of mental health specialists with good communication about the plan is the ideal approach for managing ongoing suicidal risk. The most difficult situation is where the GP is highly concerned about the patient’s risk, but public mental health services do not accept to undertake care. In these cases, it is essential that the GP sees the person frequently, and considers re-referral as needed. For GPs, this is a difficult situation and it can be helpful to seek support from peers. Assertive advocacy is often needed to ensure the patient has access to a safe space if needed, and the GP may have to speak up on behalf of the patient or take a more directive role during crisis.
Rarely, a patient is at high risk to themselves and is unwilling to accept medical assistance. The focus of care is to put in place a collaborative plan that is patient centred and the least restrictive to keep the person safe. It may be necessary to enact transfer for assessment under the Mental Health Act and, if so, requirements differ between states. It is essential that GPs create a safe space where patients feel heard and understood, even if involuntary transfer is required, though in reality it is often an irreconcilable blow to the patient’s trusting relationship with the GP.