SAFER: A Brief Intervention Involving Family Members in Suicide Safety Planning

Psychological models of suicidality emphasize the role of social factors in the development
and intensification of suicidal thoughts and behavior, including feeling like a burden on
family and friends, feelings of isolation and not belonging, and perceptions of diminished
support from one's family and social network. Despite the critical role of family factors in
protecting against suicidality, families lack education on how their behavior can help avert
or unwittingly aggravate suicidal thoughts/ behavior. Families worry about their relative but
feel uncertain of how to help and need professional guidance. Family worries about
suicidality are associated with compromised family physical and mental health and
consequently, diminished ability to offer needed support. Because suicide safety plans rely
on mobilizing support in times of crisis, families need to be equipped to provide needed
support.

Family recommendations from the VA Behavioral Health Autopsy Program (BHAP) Annual Report
6/30/15 based on interviews with 114 family members highlighted the importance of:

1. educating families about suicide warning signs:

2. improving communication between the veteran and family member

3. involving the family in the veterans' treatment to enhance support and trust

4. providing families with coaching on how to assist their loved one to seek help.

Management of suicidal behavior is covered in comprehensive family psychoeducation programs,
but there is an urgent need for a brief family-based intervention specifically focused on
suicide prevention that can be used in conjunction with the currently mandated SSP and as a
part of routine care.

Despite the enrichment of VA suicide prevention services and implementation of the national
suicide hotline, Veteran suicide completions have risen to 22 per day and suicide attempts
numbered over 15,000 in 2012. These data underscore the urgency of developing additional
interventions targeting suicidal Veterans. One potential avenue to further suicide treatment
and rehabilitation efforts is to develop strategies that maximize family support, however
almost no family interventions exist for suicidal Veterans. The construction of a Suicide
Safety Plan (SSP); a "best practice," is mandated throughout the VA system, and a vital
component of the VA's coordinated effort at suicide prevention and recovery. The pilot data
on patterns of SSP use in suicidal Veterans highlighted the importance of sharing the plan
with family or close friends. However, respondents also noted significant obstacles in their
ability to reach out to others when in distress. To the knowledge of Investigators, there are
currently no recommended guidelines or mechanisms for involving family in safety planning,
despite its inclusion as a step of the plan. "Safe Actions for Families to Encourage
Recovery" (SAFER) a novel suicide safety planning family intervention has been designed to
fill this critical gap and provide a mechanism to communicate about safety planning. SAFER, a
4-session, family intervention, combines education about suicide and suicide safety planning
with communication skills training from evidence-based practices. The aim is to facilitate
communication about suicide safety planning and to develop both a Veteran and family member
safety plan.

Data from this project will test the intervention's feasibility, acceptability and
preliminary efficacy in a Stage II small-scale randomized clinical trial in 60 moderate
suicide risk Veterans and their family members. The comparison condition will be safety
planning without family involvement plus weekly check-in phone calls. Primary Veteran
outcomes include reducing suicidal ideation/behavior. Secondary Veteran outcomes include
reducing suicidal cognitions (hopelessness, perceived burdensomeness, thwarted belongingness)
and depression and improving subjective social support. Family member primary outcomes
include reducing caregiver burden and secondary outcomes of improving suicide-related coping
and family empowerment.

Inclusion Criteria:

Inclusion criteria-Veterans:

- Eligible Veterans must be identified as at moderate risk for suicide, defined as:

- evidence of current (within the past week) suicidal ideation

- plan or intent on the Columbia Suicide Severity Rating Scale (C-SSRS), but
scoring less than or equal to 4 on the C-SSRS Behavior Scale, and without history
of a lethal suicide attempt in the last 3 months.

Inclusion criteria also include the availability of a consenting, qualifying family member
or spouse/cohabiting partner.

Inclusion criteria-family member/significant others:

- Family members/friends must meet at least three (two for nonrelatives) of five
criteria:

- is a spouse, co-habiting significant other or parent

- has more frequent contact than any other caregiver

- helps to support the patient financially

- is contacted by treatment staff for emergencies

- has been involved in the patient's treatment

Exclusion Criteria:

Exclusion criteria for Veterans and family/partners are:

- untreated or un-medicated psychosis based on the Mini-International Neuropsychiatric
Interview (MINI)

- current alcohol or drug abuse or dependence defined by a Short Michigan Alcoholism
Screening Test (SMAST) or a Drug Abuse Screening Test-10 (DAST-10)

- for couples, "severe" intimate-partner violence as defined by the revised 20-item
Conflict Tactics Scale Short Form (CTS2S)

- medical condition or life event, e.g.,

- participation in another family-based psychosocial intervention trial six months prior
to study

- limited English proficiency. Participants will be screened for inclusion/exclusion as
described above immediately after giving consent.