Coping Long-Term with Active Suicide Program

1. Introduction

Version followed: the inpatient-to-community CLASP of Miller, Gaudiano & Weinstock (Brown University / Butler Hospital, Providence RI): 3 individual in-person sessions, 1 joint patient and significant-other (SO) session, then 11 telephone sessions over about 6 months. The session-by-session content draws on the developers' own session table (Miller, Gaudiano & Weinstock 2016, Table 1, "CLASP Session Content Summary"), the VA veterans-trial protocol (Primack 2017, NCT01894841) and the ED-SAFE design paper's CLASP-ED session table (Boudreaux et al. 2013, Table 4). The 2022 Oxford Clinician Guide and the main text of the 2016 paper are not drawn on. So the step-by-step procedure inside each component, the call weeks for the inpatient version, the templates and the closing call remain [synthesis] or [uncertain]. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Boudreaux et al. 2013 Table 4; Focus 2022; Psychology Tools]

• What it is. CLASP is a brief adjunctive suicide-prevention programme for people at acute risk during care transitions, especially discharge from a psychiatric inpatient unit or emergency department (ED). It is explicitly not psychotherapy. A trained "advisor" works in a case-management style alongside the person's existing treatment, adding to it rather than replacing it. [source: Focus 2022; div12 webinar page; Brown news 2022]
• Lineage. It adapts Acceptance and Commitment Therapy (ACT), used for values clarification, and the Family Intervention Telephone Tracking (FITT) model, which grew out of the McMaster Model of Family Functioning and is used for SO involvement, telephone problem-solving and communication. Problem-solving therapy is a core strategy. [source: Focus 2022; div12; Psychology Tools]
• How change is thought to happen. Suicidal behaviour after discharge is driven by several modifiable risk factors: hopelessness, poor social support, poor problem-solving, and poor engagement with or adherence to treatment, plus factors specific to the individual. CLASP targets each one. Values-based goals rebuild hope and a sense of a "life worth living"; enlisting an SO strengthens support; structured problem-solving tackles stressors; adherence work keeps the person in care. Repeated, tapering phone contact keeps all of this going and monitors risk through the high-risk months after discharge. Gaudiano says the aim is "to help patients build a life worth living", alongside suicide prevention. [source: Focus 2022; Brown news 2022; Psychology Tools]

2. Framework

[source: Miller et al. 2016 Table 1 (session contents); Primack 2017 VA protocol (sequence, call length and structure, supervision); Boudreaux et al. 2013 Table 4 and ED-SAFE registry NCT01150994 (ED version); Focus 2022; Brown news 2022. The call weeks for the inpatient version were not found: [uncertain]]

Overall shape. CLASP is a hybrid programme: it starts in person during the acute episode (inpatient stay or ED/early post-discharge) and continues by telephone for about 6 months, with call frequency decreasing over time. Miller calls it a "middle ground" between intensive psychotherapy and single-session brief interventions. [source: Focus 2022; Brown news 2022]

• Call schedule. For the inpatient version, the sources say only that the 11 calls get less frequent over 6 months. The week numbers were not found [uncertain]. A pattern of weekly calls in month 1, every 2 weeks in months 2–3, then about monthly would fit, but it is illustrative only [synthesis]. Table 1 lists SO phone sessions next to patient phone sessions 1–11, and the VA protocol says SO calls follow the same plan, held separately. The exact number of SO calls is not stated [uncertain].
• ED version (CLASP-ED, ED-SAFE trial). All contact is by phone after the ED visit, over 12 months. Patient calls fall in weeks 1, 2, 4, 10, 22, 34 and 48 (7 calls), and SO calls in weeks 3, 8, 20 and 32 (4 calls). The calls in weeks 1–2 cover the content of in-person sessions 1–3: history, risk, safety/crisis plan, values, Life Plan and permission to contact the SO. The week 3 call orients the SO. Later calls check risk and symptoms, review the Life/safety plan and adherence, and do informal problem-solving. SOs were also recruited to help in emergencies. ED nursing staff did the safety planning in the ED. [source: Boudreaux et al. 2013 Table 4; ED-SAFE registry NCT01150994]
• Veterans adaptation (NCT01894841). It keeps the same 4 in-person sessions and 11 calls, added to VA usual care for recently hospitalised Veterans. The advisor introduces themselves as a CLASP treatment advisor and works more as a case manager than a therapist. It adds links to the VA: barriers to VA appointments, the Suicide Prevention Coordinator's role, and informing that coordinator of any rise in risk. [source: Primack 2017 VA protocol]
• Other adaptations. An adolescent version adds parental involvement and extra safety planning, and the Clinician Guide has a chapter on adapting CLASP for other populations and settings [source: Psychology Tools]. A trial combining CLASP with prolonged exposure for PTSD in military families is registered (NCT04284410). This is not drawn on [uncertain].
• Who delivers it. "Treatment advisors" with a master's-level degree in a mental-health or related field, trained to the Clinician Guide [source: Brown news 2022]. The VA protocol sets no credentials. It describes weekly group supervision, regular review of recorded sessions to prevent drift, remedial training for advisors who fall below the adherence and competence standard, and yearly refresher workshops. It also says relatively inexperienced clinicians with minimal training can deliver the pilot version. [source: Primack 2017 VA protocol] PSNet's report that ED physicians served as advisers in ED-SAFE is not supported by the ED-SAFE session table [uncertain]. Chapter 6 of the Guide (training) is not drawn on.
• Materials. The Life Plan is a document of questions that the patient and advisor discuss, recording the answers (for example, the person's plan of action for keeping safe). It guides every call. [source: Primack 2017 VA protocol] A later ED app derived from CLASP refers to a Life Plan and a Behavioral Health Action Plan [source: Larkin et al. 2023]. The templates were not seen [uncertain].

3. Guiding principles

[source: Focus 2022; Brown news 2022; Psychology Tools; div12. Re-check: Primack 2017 VA protocol confirms the adjunct-to-usual-care design, the advisor/case-manager stance, a risk check on every call, provider contact and tapering contact; Miller et al. 2016 Table 1 confirms SO involvement and collaborative monitoring. Exceptions are marked.]

• Adjunct, not therapy. Practical meaning: you do not do trauma work or deep cognitive restructuring. You support, coordinate and coach skills while the primary clinician treats.
• Advisor / case-management stance. Practical meaning: be active, practical and directive about next steps, appointments, resources and problem-solving.
• Bridge the transition. Practical meaning: start before discharge and put most of your contact into the first weeks after it, the period of highest risk.
• Target several risk factors at once. Practical meaning: every contact touches hope/values, support, problem-solving, treatment engagement and current risk, not just one of them.
• Individualise risk. Practical meaning: name this person's own warning signs and risk factors (for example a specific relationship conflict, a court date, stopping medication) and track them by name on calls.
• Values give the reasons for living. Practical meaning: goals come from what the person cares about, so the work rebuilds hope and "a life worth living" rather than only managing danger.
• Involve a significant other when possible, never as a requirement. Practical meaning: actively look for a supportive person, but run the full programme without one if none is available or appropriate.
• Separate channels for patient and SO. Practical meaning: hold separate calls so each person can speak freely. Agree the confidentiality rules in advance ([synthesis] on the rules).
• Low burden, accessible delivery. Practical meaning: short phone contacts remove barriers of transport, cost and timing. Be flexible about when calls happen.
• Monitor risk every contact. Practical meaning: assess current suicidality on every call and go back to the safety plan whenever it is present.
• Coordinate with the primary provider. Practical meaning: get consent at the start to contact the treating clinician, and contact them when risk, adherence or care problems call for it.
• Tapering intensity. Practical meaning: frequent contact early, less later. This builds the person's own coping and support and avoids long-term reliance on the advisor.
• Transdiagnostic and flexible. Practical meaning: use it whatever the diagnosis (depression, bipolar disorder, substance use, and so on) and adapt it for the ED, adolescents or veterans.
• Collaborative, non-judgmental warmth. Practical meaning: treat suicidal thoughts as understandable responses to pain and avoid lecturing. This stance follows from the ACT lineage and is not stated as a separate principle in the sources. [synthesis]

4. Intervention inventory

Scope note: the components, the session each belongs to, and the order of the phone-call agenda are now checked against the developers' session table (Miller et al. 2016 Table 1), the VA protocol (Primack 2017 VA protocol) and the CLASP-ED table (Boudreaux et al. 2013 Table 4). None of these sources gives step-by-step procedures within a component, and the Clinician Guide's Ch. 3 "Treatment Description" and Ch. 4 "Detailed Session Outline" are not drawn on. Steps written in the spirit of the parent models (ACT values work, FITT/McMaster, standard safety planning) are therefore marked [synthesis] or [uncertain]. All example language is illustrative. Check it against the Guide before formal delivery.

4.1 Programme introduction and orientation (individual meeting 1)

• Purpose / when: In-person session 1 (inpatient). Build rapport and outline the programme as an add-on to the person's usual care. Get consent for contact with the primary provider here. Formal permission to contact the SO is obtained in session 3 (4.9). [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; consent wording is [synthesis]]
• Steps: (1) Introduce yourself as their CLASP treatment advisor, not their therapist, and explain how you fit with the treatment team [source: Primack 2017 VA protocol]. (2) Lay out the structure: 3 individual sessions now, 1 joint session with a support person, then 11 short calls over about 6 months that get less frequent [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]. (3) Agree phone numbers, call times and a backup contact. (4) Agree the limits of confidentiality and when you would contact their clinician or emergency services. (5) Get a release for the primary provider. [synthesis on steps 3–5]
• Example language (illustrative): "I'm not here to replace your doctor or therapist. My job is to stay in touch over the next six months, which are often the hardest after leaving hospital, and help you keep on track with what matters to you."
• Watch for: Ambivalence about follow-up, or fear of being "watched". Frame the calls as support, not surveillance. It is working when the person gives reliable contact details and agrees a call time.

4.2 Psychiatric and suicide history; the story of the current crisis

• Purpose / when: Session 1. Take the psychiatric history and the history of suicidal thoughts and behaviour, and review the events that led to this hospitalisation. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps: (1) Invite the person to tell the story of the recent attempt or crisis in sequence: background stressors, the days before, triggers, thoughts and feelings, what they did, and what stopped or interrupted it. (2) Review earlier episodes, treatment history, and what has helped or failed. (3) Note substance use, medical problems and access to support. [synthesis on sequencing: the sources name the content, not the method]
• Example language (illustrative): "Can you walk me through what led up to coming into hospital, starting from when things first started getting harder?"
• Watch for: Shame or minimising. Reflect and normalise without probing for method detail beyond what risk assessment needs. It is working when you can name concrete triggers and a sequence.

4.3 Suicide risk assessment and individual-specific risk factors

• Purpose / when: Baseline in session 1 (current status: suicide risk, psychiatric state, treatment providers), reassessed in session 2 and at the start of every phone call. The person's own risk factors are recorded so the Life Plan can monitor and reduce them. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps: (1) Ask directly about current ideation (frequency, intensity, intent, any plan), recent preparatory behaviour, and protective factors. (2) List this person's own risk factors and warning signs (for example a relationship break-up, intoxication, a legal deadline, stopping medication) and record them in the Life Plan. (3) On calls, do a quick check of symptom severity, suicidality, treatment adherence and social support since the last contact [source: Primack 2017 VA protocol], then ask about each named risk factor. (4) Use your service's standard risk-assessment framework and documentation. [synthesis on steps 1, 2 and 4; the instruments used in CLASP sessions were not verified]
• Example language (illustrative): "Since we last spoke, have you had thoughts of ending your life? … How strong, and did you do anything to prepare?"
• Watch for: A sudden calm after agitation, giving things away, new access to lethal means, stopping treatment. Escalate (see 4.19). It is working when the person discloses openly and the named risk factors are actually tracked.

4.4 Safety plan (develop, then review)

• Purpose / when: Develop or review a safety/crisis plan in session 1 (the VA protocol puts it in session 3), review it in session 2 if needed, go over it with the SO in session 4, and use it on any call where suicidality is present, which is always dealt with first. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol] In ED-SAFE, ED nurses did the first safety plan [source: NCT01150994].
• Steps: CLASP's own template was not seen [uncertain]. A standard collaborative safety plan (the Stanley & Brown model; not confirmed as CLASP's template) covers: (1) personal warning signs; (2) internal coping strategies; (3) people and places that distract; (4) people to ask for help; (5) professional and crisis contacts; (6) making the environment safer, i.e. lethal-means counselling about secure storage or temporary removal of means, ideally agreed with the SO. Write it in the person's own words and give them a copy. [synthesis]
• Example language (illustrative): "Let's write down what you'd actually do, step by step, if things start to slide again, starting with how you'd know it's happening."
• Watch for: Generic items ("call someone"). Push for names, numbers and places. It is working when the person can say the steps without looking and reports using them between calls.

4.5 Values clarification (ACT-based)

• Purpose / when: Introduced in session 1 and continued in session 2, based on ACT values clarification. It counters hopelessness by linking the future to what the person cares about, and gives a reason to stick with treatment and change. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; div12] The VA protocol names no exercises, domains or worksheets. The Valued Living Questionnaire appears there only as a research measure.
• Steps: (1) Explain values as chosen life directions, as opposed to goals that can be ticked off. (2) Explore life domains, for example family, intimate relationships, friendships, work or education, health, spirituality, leisure and community (the domain list is ACT-typical; CLASP's own list is [uncertain]). (3) For each domain, ask what matters and what kind of person they want to be in it. (4) Help them rank which domains matter most now. (5) Notice gaps between values and current living, without judgement. [synthesis on the step detail]
• Example language (illustrative): "If things were going the way you'd want, not perfect, just headed the right way, what would you be doing more of? What would that say about what matters to you?"
• Watch for: "Nothing matters" (see section 5). Values stated as what others want from them. Values phrased as feelings ("be happy"). Reframe these into directions. It is working when the person shows more energy or engagement and can name at least one or two important domains.

4.6 Values-consistent goal setting (short- and long-term)

• Purpose / when: Session 2: turn values into short-term, values-consistent behavioural (treatment) goals. Longer-term goals are also named. Goals are revisited on calls and shared in the SO session. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Brown news "short- and long-term goals"]
• Steps: (1) For each priority value, choose one small, specific, achievable short-term goal. (2) Add one or two longer-term goals. (3) Agree the first steps and likely obstacles. (4) Write them into the Life Plan. [synthesis on steps]
• Example language (illustrative): "You said being a present parent matters most. What's one thing in the first week home that would move you in that direction?"
• Watch for: Goals that are too big, goals that depend on others changing, or goals that are all about symptom relief. It is working when goals are concrete and reported progress shows up on calls.

4.7 The Life Plan document

• Purpose / when: Session 3, most of which is spent on it. A written plan to monitor and reduce the person's identified risk factors, which then guides every call. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Focus 2022]
• Steps: The VA protocol describes the Life Plan as a set of questions that the patient and advisor discuss and record answers to, such as the person's plan of action for keeping safe [source: Primack 2017 VA protocol]. Its exact sections were not seen [uncertain]. A reasonable set of contents: values, short- and long-term goals, the safety plan, the person's own risk factors and warning signs, the treatment and aftercare plan, and support people [synthesis]. Write it together, give the patient a copy and keep one for calls. Larkin et al. (2023) also name a Behavioral Health Action Plan as a CLASP plan. How it relates to the Life Plan is [uncertain].
• Example language (illustrative): "This is your plan, in your words. On each call we'll use it as our map: what you're working toward, and what to do if things get hard."
• Watch for: A plan written by the advisor instead of the patient. It is working when the patient refers to the plan unprompted.

4.8 Treatment engagement and adherence planning

• Purpose / when: Treatment providers are recorded in session 1, providers and adherence are reassessed in session 2, and adherence is reviewed on every call. In the VA version, session 3 covers barriers to attending VA appointments and the role of the Suicide Prevention Coordinator. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps: (1) Confirm aftercare appointments (dates, clinicians, transport). (2) Ask about the person's views of treatment and medication, and past reasons for dropping out. (3) Problem-solve each barrier, such as cost, transport, side effects, stigma, waitlists or childcare. (4) Link attending treatment to the stated values. (5) On calls, check attendance and adherence and solve new barriers. [synthesis on steps]
• Example language (illustrative): "What has got in the way of sticking with treatment before? Let's plan around that now rather than after it happens."
• Watch for: Missed first appointments; this is a known danger point [synthesis]. It is working when appointments are kept and medication concerns are taken to the prescriber rather than acted on alone.

4.9 Identifying and engaging a significant other

• Purpose / when: Session 2 raises SO involvement. Session 3 gets permission to contact the SO and explains collaborative monitoring and problem-solving with them. An SO is encouraged but not required: having none does not end participation. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Psychology Tools]
• Steps: (1) Ask who the person trusts and sees or speaks to regularly. (2) Check whether that person is supportive or part of the stress. (3) Get the patient's consent and agree what may and may not be shared. (4) Contact the SO, explain the programme and schedule the SO meeting before discharge if possible. [synthesis on steps]
• Example language (illustrative): "Who's someone in your corner, someone you'd want to know how to help if things got hard again?"
• Watch for: An SO who is abusive, highly critical or actively using substances with the patient. Choose another person or go ahead without one. It is working when the SO agrees and turns up to the meeting.

4.10 Significant-other meeting: psychoeducation on suicide and risk factors

• Purpose / when: Session 4, held jointly with the patient and the SO. Build rapport with the SO, explain the programme, hear the SO's concerns about the patient (in the VA version, their view of the hospitalisation) and give basic psychoeducation on suicide and risk factors. In the VA version, the patient also gets brief psychoeducation in session 1 on how risk factors link to suicidality. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps: (1) Thank the SO and explain the programme and their role. (2) Ask for the SO's concerns and how they saw the recent crisis. (3) Explain briefly that risk is high after discharge, and go through the common risk factors and warning signs. (4) With the patient's agreement, share their own warning signs. (5) Correct myths: asking about suicide does not plant the idea, and supportive contact helps. [synthesis on order and wording]
• Example language (illustrative): "The weeks after leaving hospital are a time when extra support really matters. I'd like to go over what to look out for and what's most helpful."
• Watch for: Blame, anger or burnout in the SO, and a patient who is embarrassed. It is working when the SO can name the warning signs and what to do about them.

4.11 Significant-other meeting: review of the Life Plan and the SO's role

• Purpose / when: The same joint session. Review the Life Plan, including the safety plan, with the SO and agree the SO's part in supporting the patient's goals. The VA protocol says the session uses the FITT format. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps: (1) The patient presents their values, goals and safety plan, choosing how much to share. (2) Lead a discussion between patient and SO about specific support, including what the SO does if warning signs appear and, with consent, their part in securing lethal means at home (storage or removal only) [synthesis on specifics]. (3) Agree the SO call schedule and that the calls are separate. (4) If severe patient–SO conflict comes up, refer for family therapy [source: Primack 2017 VA protocol]. (5) In CLASP-ED, SOs were also recruited to help in emergencies [source: Boudreaux et al. 2013 Table 4].
• Example language (illustrative): "When you notice the warning signs we just talked about, what would actually be helpful from your partner? Let's get specific."
• Watch for: An SO who takes over or becomes controlling. Keep the patient in charge of their own plan. It is working when roles are concrete and both people agree to them.

4.12 Patient telephone contacts (about 11 over about 6 months)

• Purpose / when: Phone sessions 1–11 after discharge. The advisor makes the calls, which last 15–30 min depending on the issues and get less frequent over about 6 months. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]
• Steps (call structure): Sourced order: (1) a quick check of symptoms, suicidality, treatment adherence and social support since the last contact; (2) if suicidality is present, deal with it first and develop or review the safety plan; (3) review the Life Plan and treatment adherence; (4) problem-solve current issues and risk factors and help patient–SO communication, framed by values and the Life Plan [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol]. Then (5) summarise, agree one or two actions and confirm the next call [synthesis].
• Example language (illustrative): "Let's do our usual check: how have things been, how's your safety, how are the goals going, and what's the main thing getting in the way right now?"
• Watch for: Calls drifting into unstructured supportive chat; keep the structure light but present. It is working when risk is stable or improving, goals are moving and treatment is being kept up.

4.13 Significant-other telephone contacts

• Purpose / when: Separate calls with the SO, following the same general structure: the SO's concerns and view of the patient, a review of the Life/safety plan and adherence, and problem-solving. The VA protocol gives three aims: more social support, the SO's view of how the patient is doing, and a backup if the patient feels unsafe. The number of SO calls in the inpatient version is not stated [uncertain]; CLASP-ED used 4 (weeks 3, 8, 20, 32). [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Boudreaux et al. 2013 Table 4]
• Steps: (1) Ask about the SO's concerns and any warning signs they have seen. (2) Review the Life/safety plan and adherence from the SO's side. (3) Problem-solve issues the SO raises. [sourced] (4) Ask how the SO is coping. (5) Respect the agreed confidentiality rules. [synthesis on 4–5]
• Example language (illustrative): "How have things seemed at home from your side? And how are you holding up with all this?"
• Watch for: SO caregiver strain, and the SO reporting risk the patient did not disclose. Act on risk and follow the agreed information-sharing rules. It is working when the SO feels able to act and reports less strain.

4.14 Problem-solving

• Purpose / when: Every call, applied to current issues and risk factors and framed by values and the Life Plan. The ED-SAFE table calls it informal problem-solving. If a problem cannot be solved, the advisor may contact the provider or make calls more frequent for a while. [source: Miller et al. 2016 Table 1; Primack 2017 VA protocol; Boudreaux et al. 2013 Table 4; Psychology Tools names problem-solving therapy]
• Steps: The sources give no step model [uncertain]. Keep it brief and informal on the phone. A generic sequence from PST and McMaster/FITT work: (1) identify and define the problem concretely; (2) set a goal linked to values; (3) brainstorm options without judging them; (4) weigh pros and cons; (5) choose one and plan the steps; (6) try it; (7) review on the next call and adjust. [synthesis]
• Example language (illustrative): "Let's narrow that down. Of everything going on, which one problem, if it shifted even a bit, would make the next two weeks easier?"
• Watch for: Problems that are too global, or hopeless dismissal of every option. Shrink the problem and ask for "one small experiment". It is working when the person starts generating options themselves.

4.15 Communication skills

• Purpose / when: In the joint session and on calls, when conflict or poor communication is feeding stress. The VA protocol has the advisor help communication between patient and SO as part of problem-solving, but describes no method. Its roots are in FITT and the McMaster model. [source: Primack 2017 VA protocol; div12]
• Steps: [synthesis] (1) Identify a specific recent exchange that went badly. (2) Help the person state their need clearly and directly to the right person. (3) Rehearse briefly on the phone. (4) Plan when to try it. (5) Review on the next call.
• Example language (illustrative): "What did you want them to understand? Let's try saying it in one clear sentence."
• Watch for: Escalating family conflict, which is a risk factor. It is working when the person reports clearer exchanges and less conflict.

4.16 Strengthening social support

• Purpose / when: Throughout. Social support is checked on every VA call, and increasing it is a stated aim of SO calls. [source: Primack 2017 VA protocol; Psychology Tools]
• Steps: [synthesis] (1) Map current supports. (2) Find relationships linked to values that could be rebuilt. (3) Set small contact goals. (4) Link the person to community or peer resources. (5) Track this on calls.
• Example language (illustrative): "Who's one person you've drifted from that you'd like to reconnect with? What would a small first step look like?"
• Watch for: Withdrawal, which is often an early warning sign. It is working when contact with supports increases.

4.17 Liaison with the primary treatment provider

• Purpose / when: When a problem cannot be solved on the call or risk rises. With permission, the advisor contacts the primary provider and may make calls more frequent for a while. In the VA version, the Suicide Prevention Coordinator is told of any rise in risk. [source: Primack 2017 VA protocol; Focus 2022]
• Steps: [synthesis] (1) Get a release at enrolment. (2) Contact the provider when risk rises, treatment is missed or stopped, there are medication concerns, or there is a new crisis. (3) Share a concise summary covering risk, Life Plan goals and barriers. (4) Tell the patient you have done so, except where the situation is an emergency.
• Example language (illustrative): "I think Dr. X would want to know the side effects are making you skip doses. Shall we call together, or would you like me to let them know?"
• Watch for: Drifting into a parallel treatment role. It is working when the provider acts on the information and care is coordinated.

4.18 Values check on calls (tying problems to the Life Plan)

• Purpose / when: Every call. Problems are discussed using values strategies and with reference to the Life Plan, which keeps hope and direction alive. [source: Primack 2017 VA protocol; Focus 2022]
• Steps: [synthesis] (1) Remind the person of one or two core values. (2) Ask what values-based steps they took. (3) When discussing a problem, ask which response fits their values best. (4) Update goals as circumstances change.
• Example language (illustrative): "Given that being a reliable friend matters to you, which of these options fits that best?"
• Watch for: Values being used to judge or shame ("I'm failing my values"). Treat them as directions you return to, not grades. It is working when choices are made with reference to values.

4.19 Responding to acute risk on a call

• Purpose / when: Whenever the risk check shows raised or imminent risk. Sourced elements: deal with suicidality first, using the safety plan; contact the provider; make calls more frequent for a while; tell the service's suicide-prevention lead (the VA Suicide Prevention Coordinator); refer significant deterioration, or ideation with a plan or intent, to the supervising clinician for evaluation by phone or in person; escort an acutely suicidal person to emergency care; SOs can help in emergencies (CLASP-ED). [source: Primack 2017 VA protocol; Boudreaux et al. 2013 Table 4]
• Steps: (1) Stay on the line, be calm and direct, and ask about current intent and plan. (2) Work through the safety plan together. (3) If there is deterioration, or a plan or intent, escalate to the supervising clinician for same-day evaluation [source: Primack 2017 VA protocol]. (4) With consent, or as your duty-of-care policy requires, involve the SO, for example to stay with the person and secure means (storage or removal only). (5) For imminent danger, follow local emergency procedures. (6) Inform the provider and the suicide-prevention lead, add extra calls, and document. [synthesis on order and wording]
• Example language (illustrative): "I'm glad you told me. Let's take out your safety plan right now and go through it together while we're on the phone."
• Watch for: Hanging up or becoming unreachable; have an escalation plan agreed beforehand. It is working when the immediate risk falls and the next contact is confirmed.

4.20 Final contact and closure

• Purpose / when: The last scheduled call, around 6 months. Neither the 2016 session table nor the VA protocol describes how the programme ends [uncertain].
• Steps: [synthesis] (1) Review progress on values and goals. (2) Update the safety plan and Life Plan for the long term. (3) Confirm ongoing treatment and supports. (4) Name early warning signs and who to call. (5) Hand over to the primary provider.
• Example language (illustrative): "Looking back over these months, what helped most, and what will you keep doing?"
• Watch for: Distress about the ending, or rising risk near termination. Consider extra contacts and a warm handover. It is working when the person leaves with an updated plan and is in active care.

5. Handling problems

Responses found in the sources (Primack 2017 VA protocol; Miller et al. 2016 Table 1; Boudreaux et al. 2013 Table 4): having no SO does not end participation (calls go to the patient only); severe patient–SO conflict leads to a referral for family therapy; when risk rises, the advisor deals with suicidality first, uses safety planning, contacts the provider, makes calls more frequent for a while, informs the suicide-prevention lead, refers to the supervising clinician for evaluation and arranges emergency care when risk is acute; if the person is discharged before the in-person sessions are finished, the remaining sessions are held 1–2 weeks after discharge; SOs can be recruited to help in emergencies (CLASP-ED). The sources do not cover unreachable patients, missed calls or how the programme ends. Chapter 7 of the Clinician Guide ("Questions, Issues, and Concluding Comments") may cover more but is not drawn on [uncertain]. Everything else below is [synthesis] unless tagged.

• No significant other available or willing. Run the full programme with the patient alone, with all calls to the patient. [source: Focus 2022; Psychology Tools] Put extra weight on building support (4.16) and on peer or community links. [synthesis]
• The SO is unhelpful, hostile, abusive or a risk factor. Do not enrol them; pick another person or go ahead without an SO [synthesis]. If severe patient–SO conflict emerges in the joint session, refer for family therapy [source: Primack 2017 VA protocol]. If domestic abuse comes up, follow safeguarding procedures and plan safety for that situation [synthesis].
• The patient can't be reached for a scheduled call. At enrolment, agree a backup number, a time window and a rule for what happens after missed calls (for example, try again within a set period, then contact the SO, then the provider). Leave neutral messages. Repeated non-contact is itself a risk signal, so escalate according to the agreed plan. [synthesis]
• Acute risk during a call. Follow 4.19: deal with suicidality first using the safety plan, escalate to the supervising clinician for evaluation, involve the SO and the provider, make calls more frequent for a while, and use emergency services for imminent danger. [source: Primack 2017 VA protocol; Focus 2022; the emergency-services step is standard practice]
• Suicide attempt or rehospitalisation during the programme. Re-engage on the inpatient unit if possible. Run a brief review of what happened against the warning signs and safety plan, revise the Life Plan, and consider resetting the call frequency. Do not treat the attempt as failure or as a reason to discharge. [synthesis]
• Hopelessness: "there's nothing I care about". Go smaller and more concrete. Ask what they cared about before the depression, what they would want for someone they love, and what moments recently felt even slightly less bad. Accept provisional values. [synthesis, drawing on general ACT practice]
• Disengagement from outpatient care or medication non-adherence. Problem-solve the specific barrier, link treatment to their values, and contact the provider with consent (4.8, 4.17). Never advise stopping or changing medication; refer prescribing questions to the prescriber. [synthesis; adherence is a sourced target]
• Not doing goals or actions between calls. Check whether the goal is too big, whether it still fits their values, and whether it is really the person's own. Shrink it to one step and plan around specific obstacles. [synthesis]
• The patient wants the advisor to be their therapist, or calls drift into long supportive conversations. Restate the advisor role kindly, keep to the call structure, and route therapy needs to the primary clinician. [synthesis based on the sourced "not psychotherapy" framing]
• Rupture: the patient feels monitored, patronised or let down (for example after a provider or emergency contact was made). Name it, validate it, explain your reasoning briefly and ask what would make the contact feel useful. Renegotiate call times or focus within the programme's limits. [synthesis]
• Confidentiality tension between patient and SO calls. Agree the rules at the SO meeting: general updates are shared only with the patient's consent, and risk-related information is shared when safety requires it. Do not relay the SO's private worries to the patient without the SO's agreement. [synthesis]
• SO burnout or caregiver distress. Make space on SO calls for their own wellbeing, problem-solve their load, and point them to carer-support resources. [synthesis]
• Substance use as an individual risk factor. Track it as a named risk factor, add relevant coping steps to the safety plan, and link to substance-use treatment through the provider. [synthesis]
• Adolescents. Use the adapted version, with more parental involvement and more safety planning [source: Psychology Tools]. Follow consent and confidentiality law for minors [synthesis].
• Veterans / VA settings. The VA CLASP protocol (NCT01894841) adds VA links: session 3 covers barriers to VA appointments and the Suicide Prevention Coordinator's role, and the coordinator is told of any rise in risk [source: Primack 2017 VA protocol]. Work with the existing VA safety-planning processes [synthesis].
• Advisor stress and vicarious distress. Phone work with high-risk people over months is demanding. The VA protocol provides weekly group supervision, review of recorded sessions, remedial training and yearly refreshers [source: Primack 2017 VA protocol]. Add regular case review and a clear escalation route [synthesis]. The Guide's own training and supervision requirements (Ch. 6) are not drawn on [uncertain].

Sources

Sources:

• Focus (2022) review describing CLASP structure and pilot data
• Psychology Tools: CLASP Clinician Guide resource page (contents, components, adaptations)
• Society of Clinical Psychology (Div 12): CLASP CE webinar by Gaudiano, Miller & Weinstock
• Brown University news (2022): Brown professors offer a program to reduce suicide in high-risk individuals
• AHRQ PSNet: Suicide prevention in an emergency department population (ED-SAFE)
• VA HSR&D cyberseminar: CLASP Across Vulnerable Transitions in Care (Primack & Weinstock, 2019), description page only
• Larkin et al. (2023) ReachCare mobile apps, JMIR Formative Research (mentions CLASP Life Plan and Behavioral Health Action Plan)
• Gratzer, Reading of the Week: ED-SAFE summary
• ClinicalTrials.gov NCT01894841 (veterans trial)
• Miller, Gaudiano & Weinstock (2016), Table 1: CLASP Session Content Summary (PubMed Central)
• Boudreaux et al. (2013), ED-SAFE method and design, Table 4: CLASP-ED Session Content Summary (PubMed Central)
• Primack (2017), Veterans Coping Long Term with Active Suicide: IRB protocol, NCT01894841 (ClinicalTrials.gov document)
• ED-SAFE registry record NCT01150994 (ICH GCP mirror)
• Society of Clinical Psychology (Div 12): CLASP webinar page

Further reading (not drawn on; cited through the sources above): the main text of the 2016 pilot paper on PubMed Central (only its Table 1 is drawn on) and the Europe PMC full text.

Books and papers cited:

• Miller, I. W., Gaudiano, B. A., & Weinstock, L. M. (2022). The Coping Long Term with Active Suicide Program (CLASP): A Multi-Modal Intervention for Suicide Prevention. Clinician Guide. Oxford University Press (Treatments That Work). Psychology Tools lists it as 2016; the OUP ISBN 9780190095260 and the Brown announcement date it to 2022. [uncertain on the date discrepancy] Not drawn on.
• Miller, I. W., Gaudiano, B. A., & Weinstock, L. M. (2016). The Coping Long Term with Active Suicide Program: Description and pilot data. Suicide and Life-Threatening Behavior, 46(6), 752–761. Table 1 drawn on; main text not drawn on.
• Boudreaux, E. D., et al. (2013). The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): Method and design considerations. Contemporary Clinical Trials, 36(1), 14–24. Table 4 is drawn on.
• Primack, J. M. (2017). Veterans Coping Long Term with Active Suicide, IRB protocol (version dated 31 March 2017), NCT01894841.
• Miller, I. W., et al. (2017). Suicide prevention in an emergency department population: The ED-SAFE study. JAMA Psychiatry, 74(6), 563–570. Known through summaries only.