Safety Planning Intervention

1. Introduction

Version followed: the Stanley-Brown Safety Planning Intervention (SPI) as described by Stanley & Brown (2012, Cognitive and Behavioral Practice). It uses the six-step Stanley-Brown Safety Plan template (©2008), which also carries a reasons-for-living line, and the task sequence Gregory Brown teaches in current Penn Center training (2023 workshop handouts). For follow-up, it adds the structured telephone contacts of "SPI+" (Stanley et al., 2018, VA SAFE VET; call schedule as written in the NCT04893447 protocol). The original VA manual (Stanley & Brown, 2008, Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version) is not drawn on, so details found only there are not included [uncertain].

The SPI is a brief, single-session clinical intervention, usually 20–45 minutes. Clinician and client collaborate on a written, prioritised list of the client's warning signs, coping strategies, people, professional resources, steps to make the environment safer, and a reason for living. The client keeps the list and works down it during a suicidal crisis. How change happens:

• Suicidal crises are usually time-limited and fluctuate.
• A plan made in advance, in the person's own words, gives them concrete things to do to get through the peak.
• Restricting lethal means puts time and distance between an urge and a method.
• It is explicitly not a no-suicide contract.

The SPI was designed for emergency departments and other acute settings, and is also used in inpatient and outpatient therapy. Within ongoing therapy it is a component rather than a full treatment; it grew out of the safety-plan component of cognitive therapy for suicide prevention. [source: Stanley & Brown 2012; Brown 2023 PPA handouts; Stanley et al. 2018 via CDP research update]

2. Framework

The SPI is one session, not a multi-phase course. When follow-up is added (SPI+), the plan is revisited by phone. Phases A–F below are the tasks of a single session in Brown's training sequence, plus follow-up. [source: Brown 2023 PPA handouts; Stanley & Brown 2012; NCT04893447 protocol §10.1–10.2]

Settings:

• Emergency departments, crisis lines, trauma units, inpatient units at discharge, outpatient therapy, primary care (including by video), and military or correctional settings.
• In outpatient therapy the plan is revised as risk factors, skills and the social network change.
• NICE NG225 (1.11.7–1.11.8) recommends a safety plan with essentially the same components: built with the person and, where appropriate, family, held by the person, and shared as they decide. [source: Stanley & Brown 2012; NCT04893447 protocol; NICE NG225]

3. Guiding principles

[source: Stanley & Brown 2012 unless tagged otherwise]

• Collaborative, not prescriptive. Build the plan together in the client's own words. A list the clinician writes alone is unlikely to be used.
• More than filling out the form. The value lies in the conversation: narrative, rationale, likelihood checks and problem-solving. [source: Penn SPI training page, course title]
• Specific beats vague. Each entry should be concrete and personal, e.g. a named park ride rather than "exercise" [source: Brown 2023]. Plan-quality ratings score vague entries low. [source: SPISA criteria, medRxiv 2025]
• Prioritised and stepwise. Use the steps in order and escalate only if the previous step doesn't reduce risk. If the client feels unable to stay safe, they go straight to emergency help.
• Internal coping first. Self-generated strategies come first because they build self-efficacy and need no one else.
• Recent warning signs, not historical risk factors. Focus on the proximal signs of the client's own crises. [source: Brown 2023]
• Crises are time-limited. Frame every step as a way to ride out a peak that will pass. [source: Brown 2023]
• Ask "how likely?" at every step. Check likelihood of use, then identify and problem-solve barriers.
• No no-suicide contracts. Contracts lack evidence and may discourage disclosure. The SPI is a plan for what to do, not a promise.
• Means safety is routine and collaborative. Always ask about firearms. Increase time and distance between impulse and method. Use the least restrictive effective option. [source: Brown 2023; NICE NG225 1.12.5]
• The client owns the plan. The client holds the original and decides who sees it. A copy goes in the record. [source: Stanley & Brown 2012; NICE NG225 1.11.8]
• Don't force steps. The client can leave out steps they won't use. The plan should lower burden, not add to it.
• A living document. Revise it after use, after crises, and as therapy adds skills or the social network changes.
• Formulate risk; don't stratify it. Don't use risk scales or global risk levels to decide who receives a plan or treatment. [source: NICE NG225 1.6.1–1.6.4]

4. Intervention inventory

There are 18 components, in session order. The step names follow the Stanley-Brown template (©2008), which may not be reproduced without the authors' permission. Use the official form, or an EHR version licensed from the authors. Example wording is illustrative unless quoted with a source.

4.1 Risk assessment and candidacy

• Purpose: Establish that the client has had a recent suicidal crisis and can be managed with a plan, rather than needing immediate admission.
• Steps:
  1. Do a standard suicide risk assessment: current ideation, intent, planning, preparatory behaviour, recent and past attempts, and access to means.
  2. Formulate risk: drivers, protective factors, current state and how changeable it is. Don't assign a global level.
  3. Offer the SPI to anyone with a recent attempt, an interrupted or aborted attempt, preparatory acts, or ideation that amounted to a crisis.
  4. If the client can't keep safe even briefly, arrange emergency care. A plan can still be started or completed there before discharge.
• Example language (illustrative): "You've told me things got very bad on Friday. I'd like us to spend some time working out a plan for what you can do if those feelings come back. Is that OK?"
• Watch for:
  • Clients minimising risk to avoid admission.
  • Clinician pressure to "complete the form" without assessment.
  • [source: Brown 2023; Stanley & Brown 2012; NICE NG225 1.6]

4.2 Crisis narrative ("tell me the story")

• Purpose: Build a timeline of the recent crisis from the client's point of view. It supplies the warning signs for Step 1, builds rapport and shows the client that the crisis had a beginning, a peak and an end.
• Steps:
  1. Explain why you're asking: you want to understand what led up to the crisis, so the plan fits their own pattern.
  2. Ask them to start shortly before things began to go wrong (the precipitant) and move forward in time.
  3. Follow the sequence of events, thoughts, feelings, images and behaviours, including substance use.
  4. Ask what happened at the peak and what stopped them or brought the intensity down.
  5. Reflect back the timeline and note candidate warning signs and anything that helped.
  6. Keep the focus on recent, proximal events, not life history.
• Example language (illustrative): "Can you walk me through that day, starting from when you first noticed things getting worse? … What went through your mind then? … What happened next? … What made the feeling start to ease, even a little?"
• Watch for:
  • Rising distress during the retelling. Slow down and ground the client before continuing [synthesis].
  • Gaps, such as "I just snapped." Probe gently for the minutes before.
  • It is working when the client can name concrete steps in their own sequence.
  • [source: Stanley & Brown 2012; Brown 2023]

4.3 Psychoeducation: crises rise and fall

• Purpose: Give the rationale for the plan. Suicidal urges are temporary, they peak and subside, and a plan helps the client get through the peak without acting.
• Steps:
  1. Using the client's own narrative, point out how intensity rose, peaked and fell.
  2. Explain that warning signs are the cue to start using the plan early.
  3. Explain that the steps go from what they can do alone to who they can contact, and that they can skip ahead if they aren't safe.
• Example language (illustrative): "From what you've described, the worst of it lasted a few hours, then it started to ease. These feelings are very painful, but they do come down. The plan is about getting you through that window safely."
• Watch for:
  • The client hearing this as "it's not serious." Validate the pain alongside the time-limited framing [synthesis].
  • [source: Brown 2023]

4.4 Step 1: Warning signs

• Purpose: Identify the personal thoughts, images, moods, situations and behaviours that signal a crisis is building, so the plan is used early.
• Steps:
  1. Draw candidates from the narrative.
  2. Ask what they notice in themselves (thoughts, feelings, body) and around them (situations) as things start to go wrong.
  3. Push for specificity. "Thinking my partner will leave and I'll be alone" works better than "arguing" [source: Brown 2023 example, paraphrased]. Behaviours such as drinking more than usual or withdrawing also count.
  4. Write them in the client's words, about three entries (the SPISA scores up to three).
  5. Check that the client will recognise these in the moment.
• Example language (illustrative): "When you're heading toward that place again, what's the first thing you'd notice? What thought tends to show up? What would someone watching you see you doing?"
• Watch for:
  • Vague emotion words alone, such as "sad" or "stressed", score low on quality. Add the thought or situation.
  • It is working when the client can say "that's when I'll get the plan out."
  • [source: Stanley & Brown 2012; Brown 2023; SPISA via medRxiv 2025]

4.5 Step 2: Internal coping strategies

• Purpose: Things the client can do alone, without contacting anyone, to take their mind off suicidal thoughts and lower intensity. This step comes first because it builds self-efficacy.
• Steps:
  1. Explain that this step is about what they can do by themselves to distract or soothe.
  2. Ask what has helped before, including in the narrative.
  3. Brainstorm simple, specific, accessible and meaningful or soothing options. Examples: a particular walk, specific music, a shower, a pet, a hobby, a chore.
  4. Make each entry specific.
  5. Exclude activities that raise risk, such as drinking, handling weapons or being near means [source: Brown 2023].
  6. Ask the client to rank options, with the easiest or most likely to work first.
  7. For each, ask how likely they are to do it in a crisis. If doubtful, problem-solve or replace it.
• Example language (illustrative): "If you noticed those signs and you were on your own, what's something you could do for twenty minutes to take your mind off things? … Where exactly would you walk? … How likely is it you'd actually do that when you're feeling that bad?"
• Watch for:
  • Generic entries such as "distract myself" are the most common quality failure in real-world plans [source: medRxiv 2025].
  • Strategies that need equipment, money or other people.
  • It is working when the client names strategies spontaneously and rates them as likely.
  • [source: Stanley & Brown 2012; Brown 2023]

4.6 Step 3: People and social settings that provide distraction

• Purpose: If internal coping isn't enough, the client goes to people or places that offer company and distraction. They do not disclose the crisis at this step.
• Steps:
  1. Explain the distinction: at this step they don't need to say they are struggling, they just need to be around others.
  2. Elicit specific people (with phone numbers) and places, such as a café, a place of worship, a mutual-help meeting or a gym.
  3. Exclude settings with alcohol or drugs, and people who escalate distress or conflict.
  4. Check how likely they are to go or call.
  5. In youth plans, try to include at least one person available in person [source: Bettis et al. 2020].
• Example language (illustrative): "Who's someone you could hang out with, or text, who'd take your mind off things, without you having to explain how you're feeling? … Is there somewhere you could go to just be around people?"
• Watch for:
  • Isolated clients with few contacts. Public settings and structured activities can fill the gap.
  • [source: Stanley & Brown 2012; Brown 2023]

4.7 Step 4: People I can ask for help

• Purpose: If distraction fails, the client contacts a trusted person, tells them about the crisis and asks for help.
• Steps:
  1. Explain the difference from Step 3: here they do share what's happening.
  2. Elicit trusted people, preferably adults for young clients, and record contact details.
  3. Weigh the pros and cons of disclosing to each person. A good distracter may not be a good helper.
  4. Ask whether each person would help or make things worse, and how likely the client is to contact them.
  5. Identify someone who could also be given a copy of the plan.
  6. If no one is available, see 5.6.
• Example language (illustrative): "Who could you actually tell, 'I'm having a really hard time and I'm scared I'll hurt myself'? … How do you think they'd react? … What would make it hard to reach out to them?"
• Watch for:
  • The client confusing distracters with helpers.
  • Names offered to please the clinician that the client rates unlikely to call.
  • [source: Stanley & Brown 2012; Brown 2023]

4.8 Step 5: Professionals or agencies to contact during a crisis

• Purpose: List professional and crisis resources the client is willing to use, prioritised, including out-of-hours options.
• Steps:
  1. List the current clinician(s) with contact details and hours.
  2. Add an out-of-hours or after-hours service, the nearest 24-hour emergency department (address), and national crisis lines. In the US: 988 by call, text or chat. Brown's slides also list specialist lines, e.g. for LGBTQ+ youth, older adults and Black communities. Outside the US, use local equivalents [synthesis].
  3. Ask about fears of contacting services, such as forced admission or police involvement. Discuss them honestly and list only resources the client will actually use.
  4. Check likelihood of contact for each.
• Example language (illustrative): "If things got to the point where talking to friends or family wasn't enough, who's a professional you'd feel OK contacting? … Some people worry about what happens if they call a crisis line. Is that a concern for you?"
• Watch for:
  • The client listing services they don't trust.
  • Out-of-date numbers. Verify them.
  • [source: Stanley & Brown 2012; Brown 2023; NICE NG225 1.11.7]

4.9 Step 6: Making the environment safe (lethal means counselling)

• Purpose: Collaboratively reduce access to the means the client might use, adding time and distance between an urge and a method. It is done after Steps 1–5 because clients who see other options are more open to it.
• Steps:
  1. Ask which means the client has considered or would use in a crisis.
  2. Always ask about firearms, whether or not they are the method of concern. Present this as a routine question asked of everyone.
  3. Ask how many firearms there are, who owns them and how they are stored.
  4. Firearms:
     • The client should not handle the firearm to restrict it.
     • Preferred: temporary storage away from the home with a trusted third party, police (some store at no charge), a storage facility, or a gun shop or club.
     • Otherwise: store unloaded and locked, ammunition kept separately or off-site, keys or combination held by someone else, or the firearm disassembled.
  5. Medications and other means:
     • Dispose of excess or unneeded medication.
     • Keep only limited supplies at home; use shared decision-making about prescription quantities [source: NICE NG225 1.13.2].
     • Use weekly pill organisers.
     • Have someone else lock away or hold bottles.
     • Keep a crisis-line sticker, a copy of the plan or the reason for living with medications [source: Brown 2023].
  6. Agree specific actions, who will do them, by when, and for how long (e.g. two weeks, one month). Write these on the plan.
  7. Arrange how completion will be checked, e.g. confirmation from the family member, or review at follow-up [synthesis].
• Example language (illustrative): "We ask everyone this: are there any guns in your home or that you could get to? … Because acting on these feelings can happen fast when they peak, putting distance between you and a firearm for now is one of the most protective things we can do. Who could hold onto it for a while?"
• Watch for:
  • Method substitution. Restricting one method doesn't guarantee safety, so keep the other steps strong.
  • Firearm owners resisting on identity or values grounds. Frame storage as temporary and the client's own choice [synthesis].
  • This is the step most often left blank in real-world plans [source: medRxiv 2025].
  • It is working when the actions are specific and later confirmed.
  • [source: Stanley & Brown 2012; Brown 2023; NICE NG225 1.7.1, 1.11.7, 1.12.5–6]

4.10 Reason for living

• Purpose: Record the one thing most important to the client and worth living for, as a visible counterweight in a crisis. The 2008 template has a line for this: "The one thing that is most important to me and worth living for is" [source: Stanley-Brown template via UCLA copy].
• Steps:
  1. Ask what matters most to them now, in the near term or long term: people, pets, goals, events, values.
  2. Help them make it specific and personal.
  3. Write it in their words.
  4. Consider pairing it with a photo or other reminder kept with the plan or medications.
  5. In youth plans, ask about near-term and long-term future events. Use parents' input if the young person is stuck [source: Bettis et al. 2020].
• Example language (illustrative): "When things are at their worst, what's one thing you'd want to remind yourself of, something or someone worth holding on for?"
• Watch for:
  • A client who can't name anything. Don't argue; leave it open and revisit it [synthesis].
  • Most real-world entries are only moderately specific [source: medRxiv 2025].
• Note: Where this item sits in the step order varies across versions [uncertain].

4.11 Likelihood-of-use check and barrier problem-solving

• Purpose: Turn entries into actions the client will actually take. Brown describes each step as a why / what / how-likely cycle.
• Steps:
  1. After each entry, and again for the whole plan, ask how likely the client is to use it.
  2. If the answer is low or hesitant, ask what would get in the way.
  3. Problem-solve: simplify the entry, swap it for another, add practical supports, or address the belief behind the doubt (e.g. "no one cares").
  4. Ask how they will remind themselves to use the plan if they forget or don't feel like it.
  5. Ask which parts they found most helpful, to build motivation.
• Example language (illustrative): "On a scale from not at all to definitely, how likely are you to actually do this when you notice those signs? … What could stop you?"
• Watch for:
  • Automatic "yes" answers. Probe with a concrete scenario.
  • [source: Stanley & Brown 2012; Brown 2023]

4.12 Rehearsal by role-play

• Purpose: Practise retrieving and using the plan, and practise asking for help.
• Steps:
  1. If time allows, have the client describe a plausible future crisis, then walk through noticing the warning signs, finding the plan and working down the steps.
  2. For Step 4, role-play the actual help-seeking conversation. With youth, role-play with the caregiver present [source: Bettis et al. 2020].
• Example language (illustrative): "Let's imagine it's next Saturday night and you notice that 'I'm a burden' thought. Where's your plan? What's the first thing you'd do?"
• Watch for:
  • Points where the client hesitates. Revise those entries.
  • [source: Stanley & Brown 2012]

4.13 Implementation: copies, storage, access

• Purpose: Make sure the plan is available at the moment of need.
• Steps:
  1. Review the full plan together and explain how to use it.
  2. Give the client the original and keep a copy in the record.
  3. Agree where it will be kept: wallet, bedside, phone photo or note, an app or other electronic copy. Multiple copies are fine.
  4. Discuss how they will retrieve it during a crisis.
• Example language (illustrative): "Where would this need to be so you'd actually see it when things get bad? Would a photo on your phone help too?"
• Watch for:
  • A plan left in the clinic.
  • At follow-up, ask whether they could find it.
  • [source: Stanley & Brown 2012; Brown 2023]

4.14 Sharing the plan and involving supports

• Purpose: Enable a trusted person to recognise warning signs, support coping and help with means safety.
• Steps:
  1. Ask whether it would help to give a copy to anyone, and to whom.
  2. Discuss what to share and how. Respect refusal; the plan must work without sharing.
  3. With consent, bring the person in to review the plan, especially Steps 4 and 6.
  4. NICE NG225 says to develop the plan with family and carers where appropriate, and to share it with professionals as the person decides.
• Example language (illustrative): "Is there someone you'd like to have a copy of this, so they know how to help?"
• Watch for:
  • Including family who are a source of conflict. Stanley & Brown advise caution with adolescents' families in high conflict.
  • [source: Stanley & Brown 2012; Brown 2023; NICE NG225 1.11.8]

4.15 Structured follow-up contacts (SPI+)

• Purpose: Monitor risk during the high-risk period after an acute episode, keep the plan live, and bridge to treatment.
• Steps (VA/SAFE VET model as written in the NCT04893447 protocol):
  1. Make the first call within 72 hours of the visit or discharge. Make at least three attempts.
  2. Make further calls around days 7, 14, 30, 60 and 90, adjusted to the client's availability. The VA study required at least two contacts.
  3. Each call has three parts:
     • a brief suicide risk check, deciding whether immediate rescue is needed;
     • a review of whether the plan was used, what helped, and revisions;
     • support for treatment engagement, problem-solving barriers such as appointments, transport or ambivalence.
  4. Revisit lethal-means actions.
  5. Stop once the client is engaged in outpatient care or declines further contact.
  6. Urgent clinical needs override the schedule. Follow your service's crisis procedures.
• Example language (illustrative): "I'm calling to check in after your visit on Monday. How have things been? … Have any of the warning signs come up? Did you use your plan? What helped, and what didn't? … Did you make it to your appointment?"
• Watch for:
  • Clients who can't be reached. Use the agreed alternate contacts and follow the protocol.
  • Signs the plan was not used. Treat these as information for revision, not failure.
  • Call duration isn't specified in the sources [uncertain].
  • [source: NCT04893447 protocol §10.2; Stanley et al. 2018 via CDP update; Brown 2023]

4.16 Reviewing and revising within ongoing therapy

• Purpose: Keep the plan accurate as skills, risks and relationships change.
• Steps:
  1. Review the plan whenever there has been a crisis, a near-miss or ideation since the last session.
  2. Debrief what was used, what worked and where the client got stuck.
  3. Add skills learned in therapy to Step 2.
  4. Update contacts and means status.
  5. Keep revising for as long as risk persists.
  6. Check the plan with the person and follow it in care decisions [source: NICE NG225 1.5.6].
• Example language (illustrative): "Let's pull out your safety plan. Since we last looked at it, has anything changed, any new people, new things that help?"
• Watch for:
  • A plan that is never revisited.
  • The review cadence is not specified in the sources [uncertain]; review at each session while the client is at risk [synthesis].
  • [source: Stanley & Brown 2012]

4.17 Adaptation for adolescents and families

• Purpose: Fit the plan to a young person's development and involve caregivers, especially for means safety.
• Steps (Bettis et al. 2020 ED adaptation):
  1. Warning signs: Elicit with the youth, using caregivers to help if the youth can't identify any. Give examples of triggers and body sensations. Use visual aids for youth with developmental disabilities.
  2. Internal coping: Choose strategies the youth can do alone that won't spark conflict at home. Share them with the caregiver and ask how they can support them.
  3. People to distract: Include at least one person available in person.
  4. People to ask for help: Include at least one adult. If none, discuss with the caregiver how they can support the youth, and what the youth wants them to do or avoid when distressed.
  5. Professional help: Include crisis text options. Schedule outpatient care before discharge where possible.
  6. Means safety: Counsel caregivers on firearms, sharps, lighters and medications. Provide a lock box or bag. Use decision aids such as Lock to Live for resistant caregivers.
  7. Reasons for living: Draw on near-term events; use parents' input if needed.
• Example language (illustrative, to a parent): "Locking up medicines and any firearms for the next while is one of the most effective things families can do. It's temporary and it really matters."
• Watch for:
  • Conflictual caregivers [source: Stanley & Brown 2012].
  • Confidentiality boundaries: agree with the youth what will be shared [synthesis; not covered in the sources].
  • [source: Bettis et al. 2020]

4.18 Documentation and quality self-check

• Purpose: Make sure the plan is complete, specific and auditable.
• Steps:
  1. File a copy of the plan in the record, with the means-safety actions and their timeframe.
  2. Note reasons for any blank step, e.g. the client declined or no contact is available.
  3. Note the client's likelihood rating, who the plan is shared with, and the follow-up arrangements.
  4. Self-audit against the quality criteria behind the Penn rating tools. The Safety Planning Intervention Rating Scale (SPIRS) rates clinician competence and is used in Penn training. SPISA rates plan quality on each step, from absent or vague up to highly personalised.
  5. Don't reproduce either instrument; obtain them from the Penn Center [uncertain: items not seen].
• Watch for:
  • Templates filled with generic entries.
  • Empty means-safety sections.
  • [source: Penn SPI training page; medRxiv 2025 SPISA description]

5. Handling problems

Each item is tagged by source. Untagged sub-points within a [synthesis] item are the author's own guidance.

5.1 The client won't engage with or refuses the plan

• Don't push the form. Return to the narrative and the rationale, and offer to start with just one or two steps. Clients may leave out steps they won't use. [source: Stanley & Brown 2012]
• If refusal comes from hopelessness ("nothing will help"), validate it. Ask what they would be willing to try for just the next 24 hours, and document what was offered [synthesis].
• Never substitute a no-suicide contract. [source: Stanley & Brown 2012]

5.2 Low likelihood of use (ambivalence)

• Identify barriers and problem-solve them. Simplify entries and role-play using the plan. [source: Stanley & Brown 2012; Brown 2023]
• Ask what part they found most useful and build from there. [source: Stanley & Brown 2012]
• Motivational-interviewing-style exploration of ambivalence can help [synthesis; not part of the original SPI].

5.3 The client can't identify warning signs or coping strategies (stuck)

• Use the narrative step by step. Offer a menu of examples, then let the client choose and personalise them. With youth, ask caregivers. [source: Stanley & Brown 2012; Bettis et al. 2020]
• Turn vague answers into specific ones by asking "what exactly, where, when?" [source: Brown 2023]
• If nothing emerges, take one small concrete strategy into the coming week and debrief it at follow-up [synthesis].

5.4 Overwhelm or rising distress during the session

• Pause the narrative and use brief grounding or a breathing break. Shorten the retelling to the essential minutes before the crisis, then move to coping steps [synthesis].
• Reassess acute risk. If the client cannot keep safe, move to emergency care. A partial plan is still better than none [source: Stanley & Brown 2012 on imminent risk; partial-plan point is synthesis].

5.5 Short on time (ED, crisis line)

• Combine Steps 2 and 3 where needed. Prioritise warning signs, at least one coping strategy, crisis contacts and means safety. [source: Bettis et al. 2020]
• Schedule a follow-up contact to complete the plan [source: NCT04893447 protocol; completion point is synthesis].

5.6 No one to contact (isolation or conflict)

• Use public settings, mutual-help groups and structured activities for Step 3 [source: Stanley & Brown 2012 examples].
• For Step 4, explore lapsed contacts, a faith or community figure, or a peer worker. Lean on Step 5 resources, and make building connection a treatment goal [synthesis].
• Document the barrier and continue with the other steps. [source: Stanley & Brown 2012]

5.7 Fear of services (admission, police)

• Discuss these fears openly, explain realistically what happens when a crisis line or service is contacted, and list only services the client will use. [source: Stanley & Brown 2012]
• Be honest about your own duty-of-care limits rather than promising confidentiality you can't keep [synthesis].

5.8 Resistance to means safety

• Address means after the coping steps. Present the firearm question as routine, and emphasise that restriction is temporary and that suicidal crises can be brief. [source: Stanley & Brown 2012; Brown 2023]
• Offer graded options: off-site storage, then locked and unloaded storage with ammunition kept separately, then keys held by another person. Use the least restrictive effective option. [source: Brown 2023; NICE NG225 1.12.5]
• For caregivers, give psychoeducation and use a decision aid (Lock to Live). [source: Bettis et al. 2020]
• Document what was and wasn't agreed. Revisit it at every contact [synthesis].

5.9 Non-adherence: the plan wasn't used in a later crisis

• Debrief without blame. Ask whether they noticed the warning signs, whether they had the plan with them, and which step failed. [source: Brown 2023 follow-up task]
• Revise the plan: earlier or clearer warning signs, easier strategies, better storage, phone reminders [synthesis].

5.10 Rupture: the client feels processed or coerced

• Signs: a client who experiences the plan as paperwork or a liability exercise.
• Name it, acknowledge it, and return to the collaborative stance. Ask what would make the plan genuinely theirs, and let them write or edit entries themselves [synthesis].
• The developers stress that SPI is "more than filling out the form" [source: Penn training course title].

5.11 Substance use

• Exclude substance-using settings from Step 3. Include increased use as a warning sign, and remove alcohol from the home as part of environment safety. [source: Stanley & Brown 2012; case example]

5.12 Repeated crises and frequent presentations

• Review and revise the plan each time. NICE advises a multidisciplinary review with a named coordinator, and a jointly developed safety plan, for people with frequent episodes or where treatment isn't working. [source: NICE NG225 1.5.17]
• Ensure the SPI is embedded in ongoing suicide-specific treatment rather than repeated in isolation [synthesis].

5.13 Clinician anxiety or form-filling under pressure

• Competency-based training with role-play and SPIRS-rated feedback is the developers' remedy. [source: Penn SPI training page]
• Use peer review of plans against quality criteria (specificity, means section completed) [synthesis].

Sources

Sources:

• Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk (Stanley & Brown 2012, full text)
• Safety Planning Workshop Handouts, Gregory K. Brown, PPA Fall Conference 2023
• Stanley-Brown Safety Plan Template ©2008 (UCLA reprint with permission)
• Training for the Safety Planning Intervention, Penn Center for the Prevention of Suicide
• Suicide Prevention Among Recipients of Care, study protocol NCT04893447 (SPI+ follow-up procedures)
• CDP Research Update, Sept 2018 (summary of Stanley et al. 2018)
• NICE NG225 Self-harm: Recommendations
• Bettis et al. 2020, Safety Planning Intervention for Adolescents (Psychiatric Services; PMC)
• Exploring LLMs for Automated Safety Plan Scoring (medRxiv 2025; describes SPISA)
• Nuij et al. 2021 meta-analysis abstract (suicideinfo.ca)

Further reading (not drawn on):

• Stanley, B., & Brown, G. K. (2008). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. US Department of Veterans Affairs. Not readable as text [uncertain].
• Stanley, B., Brown, G. K., Brenner, L. A., et al. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. Read via secondary summaries only.