Adapting the Safety Planning Intervention for use in a veterans psychiatric inpatient group setting.
Article Type: Report
Subject: Veterans (Psychological aspects)
Suicide (Prevention)
Suicide (Research)
Authors: Rings, Jeffrey A.
Alexander, Patricia A.
Silvers, Valerie N.
Gutierrez, Peter M.
Pub Date: 04/01/2012
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2012 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: April, 2012 Source Volume: 34 Source Issue: 2
Topic: Event Code: 360 Services information; 310 Science & research
Product: Product Code: E198380 Veterans
Organization: Government Agency: United States. Department of Veterans Affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 287390290
Full Text: The Department of Veterans Affairs (VA) recently has adopted the Safety Planning Intervention (SPI; Stanley & Brown, 2011), a brief collaborative intervention, for use with veterans who are at high risk of suicide. The SPI is a hierarchical list of strategies for veterans to use in coping with a suicidal crisis. Its developers recommended that it be used with individual psychiatric inpatients working toward discharge, but its utility in a group format has not previously been addressed. This article describes the facilitation of a safety planning group with psychiatric inpatients at a large urban VA medical center. It depicts each step in the safety plan and offers case examples, anecdotal support, and specific considerations for its use in groups. Directions for further research are also discussed.

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Suicide, an extreme form of self-directed violence (SDV; Brenner et al., 2010), is a leading cause of death in the U.S. To reduce the number of suicides among its constituents, the U.S. Department of Veterans Affairs (VA) recently adopted the Safety Planning Intervention (SPI; Stanley & Brown, 2011), which is a brief collaborative and comprehensive intervention designed specifically for persons who have been determined as being at high risk for suicide (Stanley & Brown, 2008). When working with suicidal individuals, it can be used as one segment of a more comprehensive mental health care treatment plan. Taking 20 to 45 minutes to complete, the SPI is a hierarchical list of strategies that veterans at high risk can keep on hand to cope more effectively with a suicidal crisis.

The SPI and examples of its use with an inpatient psychiatric group is described here in detail. In the examples, all identifying information has been removed or altered and pseudonyms used instead of actual names.

Although these are many safety planning strategies for working with suicidal persons (e.g., Brown et al., 2005; Jobes, 2006; Linehan, 1993; Rudd, 2006), the focus has been on outpatients. And while Stanley and Brown (2008) emphasized that the SPI should be revised as needed, they thought it might be most useful in more time-limited formats, e.g., when it is unlikely that persons will engage in long-term treatment or when a clinician believes that a simple intervention would enhance the ability to cope with suicidal urges. They therefore recommended that tire SPI be used with inpatients in preparation for discharge, because after discharge from a psychiatric hospitalization people tend not to attend follow-up appointments (Boyer, McAlpine, Pottick, & Olfson, 2000; Compton, Rudisch, Craw, Thompson, & Owens, 2006). However, we know of no other studies of the use of the SPI with inpatients. This article describes use of the SPI with an inpatient group at a large urban VA medical center. Mental health counselors should find the information encouraging if they are interested in facilitating groups in other settings.

BACKGROUND

Suicide accounted for about 36,900 deaths in the U.S. in 2009 (McIntosh, 2012), an increase from recent years. It is the 10th ranked cause of death nationally. In the armed services, suicide is a serious concern. Within the Army alone, if all are confirmed, the 164 reported suicides of active-duty soldiers in 2011 (140 confirmed; U.S. Department of Defense, 2012) would represent the most suicide fatalities on record and a 242% increase over 2004.

However, suicide completions are only part of the problem. According to the 2009 National Survey on Drug Use and Health Report (NSDUH) released by the Substance Abuse and Mental Health Services Administration (SAMHSA; 2009), in 2008 an estimated 8.3 million American adults experienced suicidal ideation and more than one million people attempted suicide. Among U.S. Army personnel, Hoge, Auchterlonie, and Milliken (2006) reported that about 1% of a sample of over 222,000 Operation Iraqi Freedom (OIF) military personnel verified having some degree of suicidal ideation, and 467 participants thought about suicide "a lot."

Suicide rates among active duty military personnel are tracked, as are the rates for veterans receiving VA care, but because most veterans are not VA patients, there is no nationwide system to track all veteran suicides (Sundararaman, Panangala, & Lister, 2008). Nevertheless, suicide among veterans is considered a significant public health problem (Brenner, Homaifar, Adler, Wolfman, & Kemp, 2009). The CDC's National Violent Death Reporting System (NVDRS), the purpose of which is to gather thorough information about suicides and other violent deaths among all individuals in a state, was funded in 2003 but is as yet active in only 17 states. A CDC report (Karch, Lubell, Friday, Patel, & Williams, 2006) based on NVDRS data gathered from the 16 states then participating estimated that about 6,500 veterans die by suicide each year, which would account for about 20% of all suicides nationwide. An estimated 18 veterans die by suicide every day, 5 of whom were receiving VA care.

Veterans are thus at significantly greater risk for suicide than the general population (Zivin et al., 2007). Within the general population, risk factors include familiarity with firearms (Miller, Azrael, Hepburn, Hemenway, & Lippmann, 2006; Miller, Lippmann, Azrael, & Hemenway, 2007); lessened social support (Joiner, 2005); and being male, older, and having medical and mental health difficulties (Goldsmith, Pellman, Kleinman, & Bunney, 2002). The highest rate of suicide completion occurs among older white males, many with a history of depression, substance abuse, or both (Bruce et al., 2004; Conwell, Duberstein, & Gaine, 2002). A considerable number of those served by the VA healthcare system fit this demographic (Kaplan, Huguet, MeFarland, & Newsom, 2007).

One risk factor identified for suicide among veterans is the presence of at least one mental health disorder (Kang & Bullman, 2008). A RAND Corporation report (Tanelian & Jaycox, 2008) noted that depression, posttraumatic stress disorder (PTSD), and a traumatic brain injury (TBI) were all independent risk factors for suicide for both civilians and veterans, but Zivin et al. (2007) found that both male and female veterans with depressive disorders are at significantly greater risk for suicide than the general population. Among veterans, those diagnosed with PTSD and two additional mental health disorders (e.g., depression and drug or alcohol abuse) were nearly six times more likely to express suicidal ideation than those suffering from PTSD alone (Jakupcak et al., 2009). Moreover, having had combat-related experiences has been found to increase the risk for suicide (Kang & Bullman, 2008; Maguen et al., 2011).

THE INPATIENT SPI GROUP

The stories the numbers tell have arguably directed attention to the topic of suicide prevention among both active duty military personnel and veterans. The SPI group studied was initiated in response to an April 24, 2008, memorandum from the Office of the Deputy Under-Secretary for Health for Operations and Management (see Department of Veterans Affairs, Office of Inspector General, 2010) mandating that a safety plan be drawn up with each veteran identified to be at high risk of suicide. Because this criterion applies to many veterans admitted to inpatient psychiatry units, they must now have an SPI before they can be discharged. The Denver VA Medical Center Suicide Prevention Team, which includes one of this article's authors (VS), decided to use the SPI in a psychiatric inpatient group because in line with many of the therapeutic factors set out by Yalom and Leszcz (2005), a group format can (a) help to reduce members' feelings of stigma and shame about their suicidality and instead offer a sense of universality (disconfirmation that their own ideation is entirely unique); (b) allow for vital psycho-education; (c) give veterans the opportunity to be altruistic to others and thus feel needed and important; (d) encourage development of socializing techniques; and (e) provide a forum in which group members can model behavior after either the facilitators or other members.

The SPI is easy to learn and use; staff can be quickly trained on its use; and clinicians can use it in treating suicide risk regardless of their theoretical orientation (Stanley & Brown, 2011). Because of its apparent utility as a standalone intervention (a VA clinical demonstration project is formally evaluating it nationally), the SPI was selected over other approaches to address acute suicidal crises during longer-term inpatient or outpatient treatment (e.g., Jobes, 2006; Rudd, Joiner, & Rajab, 2001). The SPI is structured on such evidence-based practices as means restriction, distraction techniques to facilitate short-term emotional regulation, and use of emergency contacts (B. Stanley, personal communication, June 15, 2011). It is also listed in the Best Practice Registry for Suicide Prevention of the Suicide Prevention Resource Center/American Foundation for Suicide Prevention (2010).

Group Selection and Rules

The inpatient SPI group meets weekly for about one hour. Typically each meeting is co-facilitated by two clinicians experienced in safety planning. During morning rounds on the day of the inpatient SPI group, members of the psychiatry team select veterans they consider to be appropriate for inclusion. Typically, all veterans admitted to the unit due to SDV ideation, behaviors, or attempts are considered appropriate; patients experiencing significant dementia or active psychosis or who are having difficulty maintaining behavioral control are not. Immediately before the inpatient SPI group starts, the facilitators introduce themselves separately to all prospective group members and ask them to attend. Prospects are informed that the purposes of this group are to introduce them to the concept of safety planning and to help each of them to draw up their personal plan. The group is not meant to replace any individualized mental health treatment they are to receive either before or after discharge.

Since completion of a safety plan is a requirement for discharge, attendance, though voluntary, is strongly encouraged. Veterans are welcome to attend more than once: Arguably, emotional and cognitive states can change considerably as treatment gains begin to take hold. Thus, as veterans work toward discharge, their ability to apply themselves to the task of creating a safety plan often improves. For many, what may begin as a somewhat limited and brief SPI can turn into something much more meaningful as the veteran becomes increasingly able to access more internal options and coping strategies. Furthermore, veterans who had been quiet throughout their first inpatient SPI group meetings may later become de facto co-facilitators. It also is common for veterans to provide many safety planning strategies for each other. Because of their shared military experience, they often have more credibility with some veterans than the official facilitators, who may be viewed as outsiders who could never fully understand veterans and their unique situations.

For instance, John attended his first inpatient SPI group after admission due to a potentially lethal suicide attempt by overdose. His unabated depressive symptoms and profoundly blunted affect led him to participate only minimally in the discussion; he only once lethargically voiced his frustration at having been hospitalized involuntarily. Nevertheless, he managed to listen attentively and nod in agreement with others from time to time. The following week John agreed to attend a second SPI group. During that meeting, the facilitators witnessed a marked improvement both in the degree of his participation and in his "buy-in" of the notion of safety planning. He was able to pinpoint many of his personal warning signs (see Step 1 below), such as increased irritability toward his family; not wanting to eat, bathe, or take his medication; and an increased tendency to isolate and withdraw from others. John offered several examples of activities he could do to distract himself (see Step 2), such as listening to music, exercising, reading, or surfing the Internet. He listened attentively, wrote down pertinent information, and frequently and appropriately commented that he understood how planning ahead could help him to refrain from SDV in the future. He also was able to offer support and encouragement to other group members in response to their own ideas.

Instructions to Group Members

At the outset of each inpatient SPI group, the facilitators acknowledge that veterans have challenging problems and genuine stressors in their lives; engagement in the SPI process is neither a fix-all for the problems nor an attempt to minimize or avoid addressing them. The veterans are informed that having a safety plan can help them regain a sense of control over their lives by redirecting them to safer and healthier behaviors in a crisis. The facilitators emphasize that a major purpose of the safety plan is to give the veteran the time that is critically needed for difficult yet arguably time-limited feelings to pass. Ideally development of a safety plan should not be viewed or managed as a single event (Stanley & Brown, 2008). Rather, veterans are encouraged to consider the safety plan as a fluid document that likely will change as life circumstances evolve, as people come or go from their lives, and as they gain insight into their warning signs, internal coping abilities, and external coping methods.

During a suicidal crisis, all a veteran may be able to focus on is recent personal history, little of which may have been positive. Nevertheless, the majority of veterans who have participated in the inpatient SPI groups were successful during their military careers. The strengths and skills developed in the military can therefore be used as catalysts to expand coping strategies. Throughout the group meeting, the facilitators look for opportunities to highlight adaptive strategies that the group members mention and tie them back to earlier military training. For example, military experience typically means that veterans are familiar with drawing up a specific plan or having written orders for each major activity. They understand that preparation enhances success or survival not only in deployment but in any undertaking. This train of thought seems to readily translate to safety planning. Members also are encouraged throughout the session to advise and support each other and empathize with each other's struggles. They are reminded of the military concept of never leaving a comrade-in-arms behind and having (in current military vernacular) a "battle buddy" or "wingman." As members of the group, they can all work together to help ensure each other's survival (Casares, 2008).

SAFETY PLANNING: ONE STEP AT A TIME

At the outset of the meeting, each member is given a blank SPI form to complete during the meeting. The SPI has six specific steps, which are described here with anecdotal examples of their use within the group.

Step 1: Recognizing Warning Signs

One of the most effective ways to stave off a suicidal crisis is to become more aware of the physical, cognitive, emotional, or behavioral warning signs that typically occur right before a crisis (Stanley & Brown, 2008). Ideally this makes it possible to preemptively address the problem before it becomes a full-blown crisis. In the SPI group, veterans are encouraged to discuss with the facilitators and each other the warning signs they experienced before their most recent suicidal crisis and other warning signs they may have, and to write these signs on their SPI forms. These discussions typically do not lead to any group members becoming emotionally triggered, unlike what can happen when other group members share intimate details of their suicidal crises (e.g., how one's suicide was attempted). Rather, the simple act of sharing a personal warning sign often leads to greater identification, compassion, and cohesiveness in the group, smoothing the way for problem solving and support during discussion of the SPI's later steps. Common warning signs are feelings of anxiety, depression, anger, irritation, and isolative behaviors--the act of (or the desire to be) picking fights with those close to them or strangers; hearing news about current combat missions; or being around those who "never served."

Such thoughts, feelings, or behaviors often lead to drug or alcohol use before they spiral into suicidal crisis. Jeremy, a twice-deployed OIF veteran who lived near the Army post where he had been stationed, stated that before hospitalization he had quit his job, broken up with his girlfriend, stopped leaving his apartment, and arranged to have the liquor store make daily deliveries. Warning signs and triggers included seeing soldiers in uniform (reminding him of friends he had lost); feeling disgust and contempt when seeing "civilians who never had to take a stand on anything but enjoyed all the freedoms of an American"; and feeling guilt and anxiety when he heard news about Americans in Iraq.

Susan, a former Army supply sergeant, had never expected to be in direct combat. As OIF progressed, infantry combat units increasingly called upon active duty women to join them on patrols. As Susan described it, when a patrol entered the home of a suspected terrorist, the women and children were separated from the men and had to be searched for weapons or suicide vests. She acknowledged that such patrol encounters were emotionally difficult for her and that she constantly felt ill-prepared for the role she had been asked to take. For her, triggers and warning signs included encountering local women wearing a head covering that might indicate Muslim descent, seeing or hearing about women in any vulnerable situation, and watching children play. When triggered, she reported immediate feelings of anxiety, fear, and helplessness and had reached the point that she could not be around her nieces, nephews, or the children of friends without feeling depressed, anxious, and suicidal.

Step 2: Using Internal Coping Strategies

In Step 2, veterans are encouraged to devise a list of solitary activities to do to distract themselves from immediate stressors and prevent escalation of a suicidal crisis without having to contact anyone else (Stanley & Brown, 2008). Though this step does not try to resolve the crisis directly, it has several rationales: First, veterans may build confidence in how to cope more effectively with their suicidal crises on their own rather than always having to rely on others, however briefly. Learning to self-soothe ideally has both short- and long-term therapeutic benefits (Stanley & Brown, 2008). Here, the veteran ultimately may learn how to gain a modicum of control over certain painful affective states and crisis-laden situations that previously seemed to be unattainable. Second, given the understanding that suicidal crises are of limited duration, this step aims to help veterans to distract themselves for however long it takes to allow enough time for the crisis to dissipate without direct intervention.

Typical internal coping strategies that veterans in our groups proposed were reading, watching comedies, tinkering in the garage, walking or otherwise exercising, listening to music, fishing, and participating in other outdoor activities. Since some of these options had ]imitations (e.g., going for a hike during winter in Colorado), the veterans are asked about possible problems with their chosen options, and then encouraged to devise a wide variety of back-up strategies. Here again ingrained military skills may prove useful. For example, veterans are asked about stress inoculation techniques learned in the service to induce a sense of calm, such as controlled breathing exercises when using firearms (Grossman & Christensen, 2008). One benefit is that this strategy may be implemented ad infinitum, nearly anywhere at any time.

It is quite common for a veteran to mention a particular warning sign in Step ] but fail to address it in Step 2. For example, symptoms of anxiety often are described as warning signs, yet no anxiety-reducing strategies are brought up later. In such cases, the facilitators may suggest anti-anxiety exercises (e.g., guided visualization, progressive muscle relaxation) to either jog the veterans' memories or introduce them as future goals in therapy.

Step 3: Utilizing Social Contacts that Can Serve as a Distraction from Suicidal Thoughts and Who May Offer Support

Veterans should move on to Step 3 of the SPI if using internal coping strategies (Step 2) does not bring the suicidal crisis to a manageable level (Stanley & Brown, 2008). Here, veterans are encouraged to list on their SPI forms safe social settings and persons who may be able to distract them from the suicidal crisis. As in Step 2, veterans are not yet disclosing their suicidal crisis to others; the aim is to distract themselves for the time being. In introducing this step, the facilitators discuss how just being around others in a neutral environment, regardless of whether there is actual interaction, may change the veteran's frame of reference just enough to buy crucial time for" the crisis to pass. Increased feelings of connection to others also may help alleviate a suicidal crisis (Joiner, Van Orden, Witte, & Rudd, 2009). Typical examples discussed within the group were calling a friend, going to the movies, working on a project with a friend or family member, or going to a favorite restaurant.

During this step, group members are strongly encouraged to write phone numbers directly on their SPI forms, even if they had already logged the numbers into their cell phones. This strategy is highlighted because cognitive disorganization tends to increase when one is overwhelmed by difficult emotions (Maltsberger & Weinberg, 2006). For example, writing a friend's phone number on the SPI may help ensure that contact can be made if the veteran cannot find the cell phone. Anecdotally, sharing stimulating ideas with each other appears to increase group cohesiveness and internal support. Examples of safe social settings often include parks, the library, church, the local Veterans of Foreign Wars branch, or sobriety support groups such as Alcoholics Anonymous, Narcotics Anonymous, and Rational Recovery. Many veterans also reported going to a VA medical center to surround themselves with other veterans.

Step 4: Contacting Family Members or Friends Who May Offer Help

If the strategies for Steps 2 and 3 do not provide enough immediate relief, Stanley and Brown (2008) suggested that veterans in a suicidal crisis move to Step 4--identifying individuals in their natural social environment to whom they can acknowledge being in crisis. Veterans are asked to write down social contacts, especially close friends and family members, who can be relied on to provide support. This is the first step in which veterans disclose to another person that they are in suicidal crisis.

For many veterans, Step 4 may be the most difficult. One unfortunate yet common occurrence has been for veterans in the group to report that they do not have people on whom they can rely for support, for a variety of reasons, such as homelessness, alienation from family, or the perception that friends are incapable of providing the support needed. Such was the case with Roger, a single Vietnam veteran in his early 60s. Roger had been quite engaged in the group to that point, sharing with the other members what he had written on his safety plan for Steps 1 through 3. Now, at Step 4, he stared despondently at this part of the form, which remained entirely blank. One of the facilitators asked him who he could list. "Nobody," he said quietly.

After a brief pause, Roger explained, "The only people I talk to are my neighbors, and they're all just a bunch of drunks. I can't trust those fools with anything, no matter what." In such circumstances, the facilitators normalize this experience as a problem that people often have during major life transitions of any kind. They also point out that people diagnosed with mental health disorders often have withdrawn from friendships or chosen inappropriate friends or damaged relationships. The likely result, then, is the reality that the veteran may have few if any people to turn to in times of crisis. In these instances, group members are told that not everything on the SPI form must be completed in-session; it is a fluid document that they may add to and adjust over time as life circumstances improve. Also, they are encouraged to bring this issue to the attention of their personal mental health counselors, who may be better equipped to address this as a long-term therapeutic issue.

Another strategy that may be successful is to reintroduce and reincorporate the concept of having a battle buddy or wingman (Casares, 2008). This could be someone for whom they would provide help and support and who would reciprocate: someone toward whom they may feel a sense of responsibility and duty. Typically, from the first day of basic training the buddy system extends through most phases of military life, where the main benefit often is safety or survival; buddies work together to provide monitoring, assistance, or even rescue during a crisis. Many group members are able to recall incidents in which encouragement and support from a battle buddy dealing with similar mental or physical demands provided the impetus to continue onward. Not surprisingly, group members sometimes volunteer to serve in this capacity for each other and exchange contact information.

In a particularly touching example, during one group session Bill steadfastly denied having anyone in his life that he could list for this step. Without any prompting, another group member, Dave, adamantly but respectfully insisted that Bill list him as a support on his SPI form. Eventually, Bill slowly slid his form across the table to Dave, who promptly wrote Iris name and two phone numbers on it. The facilitators then paused the group to process this interaction by asking Dave about what had just occurred. Taking his cue perfectly, Dave looked directly at Bill and said matter-of-factly, "Dude, you've listened to me a lot in here, and you've given me a lot of good advice with all my troubles. If you have no one else...well, at least you got me. Understood?" Dave fixed his gaze on Bill, who eventually nodded. The renewed camaraderie displayed by these veterans and their willingness to volunteer to give additional support, particularly once this step is placed within a military context, is powerful and vital. Arguably, both Bill and Dave received a therapeutic benefit: Bill made a connection with someone who might help him stave off a suicidal crisis. Dave displayed altruism, itself a vital therapeutic factor (Yalom & Leszcz, 2005), and had the opportunity to feel both needed and useful to another.

A crucial caveat should be added to this example: It would be vital for a clinician to later revisit such interactions individually with group members in positions similar to Bill's to discuss the appropriateness of, and their degree of comfort with, including such persons on their SPIs.

Step 5: Contacting Professionals and Agencies

By now, group members ideally have a variety of techniques to distract themselves from or relieve a suicidal crisis. If relief has not yet been achieved, Stanley and Brown (2008) encouraged the veteran to utilize any professional resources available in trying to resist SDV. Veterans are asked to write on their safety plans a detailed list of providers and agencies they would be willing to contact if needed, both during and after business hours. This prioritized list should include contact information for as many as possible of the following: outpatient mental health providers (e.g., therapists and psychiatrists); local urgent care services (e.g., the nearest emergency department, VA or otherwise); the National VA Crisis Line (1-800-273-8255, press 1 for veterans); and 911 if other strategies are unsuccessful. Meurbers are provided with contact information for each of the facilitators and for the facility's suicide prevention coordinators and are given information about a short-term support/psychoeducational group to help those recently discharged from the inpatient unit to transition back to life outside the hospital.

Discussions about this step often give both facilitators and group members an opportunity to impart information (Yalom & Leszcz, 2005) about treatment options--information that may be better received from other group members than from the facilitators. For instance, the veterans typically are asked if they have ever called the National VA Crisis Line. In one group, Roland answered in the affirmative. Instantly, Larry said: "No way! I am never, ever, calling them. I heard that they always just call the police on you when you call. Every time. That's happened twice to this one buddy of mine."

One facilitator, who had extensive experience working for a crisis hotline, tried to give Larry didactic information about the general utility of crisis lines and how their use of immediate police response was typically a last resort to help keep the caller from making a suicide attempt rather than a front-line intervention. As this seemed to do little to dissuade Larry from his concerns, Roland spoke up: "I've called them a few times now, and that's never happened to me. In fact, all they've ever done is listen to my problems until I feel better. Would I call 'em again? Hell, yeah." Listening intently, Larry voiced both relief and appreciation and agreed to consider calling the crisis line if need be.

Step 6: Reducing the Potential for Use of Lethal Means

The final step of the SPI is to identify dangerous or potentially lethal means in the home environment and specify steps for eliminating or significantly limiting access to them (Stanley & Brown, 2008). For instance, reducing access to firearms is a top priority for this population. However, veterans often are highly reluctant to agree to do so for many reasons (e.g., extensive familiarity with firearms, wanting to feel safe from others). Within the group, this conundrum can be opened up for general discussion. Feedback is elicited about how access to firearms can be reduced or eliminated. Again, a group member who seems resistant to information imparted by a facilitator may be more willing to accept instruction or direct advice from another member (Yalom & Leszcz, 2005). For example, group members have recommended giving firearms to a friend or family member, securing all ammunition in an area separate from firearms, installing trigger locks on firearms, or putting all firearms in a gun safe to which the veteran has no immediate access.

Group members can be highly creative in their recommendations about making the environment safer. For instance, Lance, a former Marine who had served two tours in Vietnam, was adamant about not giving up access to the many firearms in his home, despite having held a loaded pistol to his head and debating whether he deserved to live when so many of his friends had died in combat. The guns were in a safe--and there was "no way [he was] going to give up the key." Appeals to logic and reason fell short; Lance countered every argument with one of his own: he felt safer with the guns in the house, he and his wife live in the mountains, and the closest "security" is three miles away, it was his job to protect his wife, and finally, he's a hunter and he already had tags for elk that year.

From the far end of the room, Jared, a recently returned combat medic, leaned back in his chair and asked, "So you got a freezer for all that elk meat you think you're gonna get?" Thinking the subject had been changed, Lance expounded on the virtues of his freezer, to which Jared replied, "Then freeze that mother [the gun safe key] in a block of ice and make it harder to get to. Access problem solved!" Lance nodded approvingly and wrote down the solution.

Stockpiled medications are another potentially lethal environmental hazard often mentioned. Veterans have suggested to each other a variety of options here, such as destroying all discontinued medications, asking a friend or family member to dispense the medications, and locking up all medications beyond a one-week supply. Also, given their frequency as a precipitant for suicidal ideation among veterans, restricting or eliminating access to illicit drugs and alcohol to make the environment less lethal should be emphasized. Earlier, Roger had complained of a lack of emotional support in his current social network. Now he announced he had already decided to change apartments immediately upon discharge because his apartment was next door to a liquor store. For Roger, regular copious alcohol use often led directly to SDV ideation. "If I don't get out of there, I'll eventually go right back to where I was. And then, it's only a maker of time before I... you know, do the deed," he announced.

A final component in Step 6 is to discuss use of the safety plan. For instance, input is solicited on how group members could make safety plans more readily accessible. Suggestions have included placing copies in several locations: one in a wallet, another on a refrigerator, or one in the car; programming the entire safety plan into a cell phone; and even reducing it to the size of a playing card, laminating it, and putting it on a keychain.

Again, the SPI group should not be considered a proxy for the individualized mental health services that patients typically receive before, during, or after discharge. The treating clinician should meet later with each group member to (a) review the safety plan together; (b) ensure that it is clinically sound; (c) verify that the patient understands how best to use it; (d) confirm that the patient did not agree to something just to avoid offending others; and (e) consider whether any updates are needed.

FINAL THOUGHTS

Suicide among veterans is a significant public health problem (Brenner et al., 2009). The VA has adopted the SPI (Stanley & Brown, 2008) as one intervention strategy within a comprehensive treatment plan when working with veterans at risk for suicide. Its use provides a structure for clinicians and patients to work collaboratively to specify a hierarchical series of coping strategies and persons and agencies to contact to decrease an imminent risk for self-harm. Although studies have examined the use of safety planning strategies with individual outpatients (e.g., Brown et al., 2005; lobes, 2006; Linehan, 1993; Rudd, 2006), none have been considered comprehensive enough to serve as stand-alone interventions. Because of the SPI's utility, its developers recommended its use with psychiatric inpatients in preparation for discharge. However, the actual practice has not yet been addressed.

The inpatient SPI group was initiated at a large VA medical center to help enhance the coping skills of veterans at high risk for suicide who might be unlikely to engage in much outpatient mental health treatment following discharge (Boyer et al., 2000; Compton et al., 2006). This paper provides anecdotal support for such use of the SPI. It may be that many of the general benefits of the group format (e.g., collaboration with peers, group cohesiveness, and opportunities for altruism between members) act as catalysts for veterans to develop robust, comprehensive, and effective safety plans.

Despite the possible challenges in bringing an acute inpatient therapy group to fruition, such as high patient turnover, navigating the group within the larger context of the inpatient unit, and the heterogeneity of psychopathology (Yalom & Leszcz, 2005), staff and patients alike regularly acknowledge the benefit of this type of group. Clinicians are encouraged to consider this novel group intervention for their own psychiatric inpatient settings.

However, one obvious current limitation is the lack of data supporting the use of the SPI with inpatient groups. It now is crucial to move beyond the anecdotal. Are members of inpatient SPI groups more confident about their ability to stay safe from SDV than nonmembers? Does attending an inpatient SPI group lead to fewer re-hospitalizations? Investigating such questions is a vital next step. It also could prove helpful to explore, both qualitatively and quantitatively, how patients view the benefits of using the SPI both pre- and postgroup attendance. Future research certainly must also consider assessing SPI use with persons from diverse backgrounds. Finally, inpatients attending SPI groups could be compared to inpatients receiving "treatment as usual" on a number of variables, such as readiness for discharge, further treatment collaboration or compliance, and risk of SDV post-discharge.

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Jeffrey A. Rings is affiliated with the University of Northern Colorado; Patricia A. Alexander with the VA Veterans Integrated Service Network 19 Mental Illness Research, Education, and Clinical Center (MIRECC); Valerie N. Silvers with the VA Eastern Colorado Healthcare System; and Peter M. Gutierrez with MIRECC and the University of Colorado School of Medicine. Correspondence related to this article should be directed to Dr. Jeffrey A. Rings. Department of Counseling Psychology, McKee Hall 201A, Campus Box 131, University of Northern Colorado, Greeley, CO 80639. E-mail: jeffrey.rings@unco.edu.

Note: The authors thank Barbara Stanley, Ph.D., Gregory Brown, Ph.D., and Michelle Steinwand, LCSW, for their guidance and support. This material is the result of work supported with resources and the use of facilities at the VISN 19 MIRECC located at the Denver VA Medical Center. Writing of the article also was supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

Disclaimer: The views expressed are those of the authors and do not represent the views of the Department of Veterans Affairs or the United States Government.
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