Suicide Prevention for Veterans: Safety Planning Intervention and Phone Follow-up Helps Lower Suicide Risk

Two images of Safety Planning Documents
PHCoE graphic
By Gregory K. Brown, Ph.D. and Barbara Stanley, Ph.D.
September 17, 2018

What is the Safety Planning Intervention (SPI)?

The SPI is a brief clinical intervention we designed to decrease future risk of suicide by providing suicidal individuals with a written, personalized safety plan to be used in the event of a suicidal crisis. The SPI has been recognized as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention for veterans and by the Department of Veterans Affairs/Department of Defense for veterans and service members. The SPI is widely used in health systems, including the Veterans Health Administration.

How does the SPI work to reduce suicide risk?

The SPI uses evidence-based strategies to reduce suicidal behavior by providing prioritized coping strategies, such as reminders of reasons for living, to successfully cope with a suicidal crisis. The SPI also includes lethal means counseling to reduce access to potential suicide methods.

The Safety Planning Intervention consists of six key steps:

  1. Identify personalized warning signs for an impending suicide crisis
  2. Determine internal coping strategies that distract from suicidal thoughts and urges
  3. Identify family and friends who are able to distract from suicidal thoughts and urges as well as social settings that provide the opportunity for interaction
  4. Identify individuals who can help provide support during a suicidal crisis
  5. List mental health professionals and urgent care services to contact during as suicidal crisis
  6. Lethal means counseling for making the environment safer

What is the most recent scientific evidence supporting the SPI?

In our recent study, the SPI was paired with follow-up contact for suicidal patients - we call this SPI+. Follow-up contact consisted of telephone contacts after patients were discharged from an emergency department (ED). Calls were made by our trained project staff, social workers and psychologists, and were initiated within 72 hours of discharge from the ED. Calls were continued on a weekly basis until patients had attended at least one outpatient behavioral health appointment or until they no longer wished to be contacted.

The follow-up telephone contacts generally included three components:

  1. Brief risk assessment and mood check
  2. Review and revision of the safety plan from the SPI, if needed
  3. Facilitation of treatment engagement

During the study, the SPI+ was administered by staff at Veterans Health Administration EDs in several locations. The SPI+ was administered to a total of 1,186 adult patients who presented to these EDs for a suicide-related concern, but for whom inpatient hospitalization was not clinically indicated. We collected data on these patients, 88 percent of whom were men, as well as a control group who were treated with usual care, for six months after the suicide-related ED visit.

Our data revealed that patients who received the SPI+ were about half as likely to engage in suicidal behaviors than the patients who received usual care (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). In addition, those in the SPI+ group were more than twice as likely to attend at least one outpatient behavioral health appointment (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001). In other words, the SPI+ was associated with a reduction in suicidal behavior and an increase in treatment engagement following ED discharge.

Where can I learn how to administer the Safety Planning Intervention?

Our 2012 publication contains more information on the details of the SPI. You can also download a blank copy of the safety plan and training manual, watch a 2017 webinar, and download its corresponding slide deck about the SPI.

Brown is a clinical psychologist and research associate professor of clinical psychology in psychiatry and director of the Center for the Prevention of Suicide at the Perelman School of Medicine at the University of Pennsylvania. He is also a research psychologist at Corporal Michael J. Crescenz VA Medical Center in Philadelphia, Pennsylvania.

Stanley is a clinical psychologist and professor of medical psychology in the Department of Psychiatry at Columbia University. She is also the director of the Suicide Prevention Training, Implementation and Evaluation program in the Center for Practice Innovations at Columbia University and a research scientist at the New York State Psychiatric Institute.

The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.

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